[Senate Hearing 111-946]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-946

                      A REVIEW OF DISASTER MEDICAL
                PREPAREDNESS: IMPROVING COORDINATION AND
  COLLABORATION IN THE DELIVERY OF MEDICAL ASSISTANCE DURING DISASTERS

=======================================================================

                                HEARING

                               before the

                  AD HOC SUBCOMMITTEE ON STATE, LOCAL,
                    AND PRIVATE SECTOR PREPAREDNESS
                            AND INTEGRATION

                                 of the

                              COMMITTEE ON
                         HOMELAND SECURITY AND
                          GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 22, 2010

                               __________

         Available via the World Wide Web: http://www.fdsys.gov

       Printed for the use of the Committee on Homeland Security
                        and Governmental Affairs


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        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

               JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan                 SUSAN M. COLLINS, Maine
DANIEL K. AKAKA, Hawaii              TOM COBURN, Oklahoma
THOMAS R. CARPER, Delaware           SCOTT P. BROWN, Massachusetts
MARK L. PRYOR, Arkansas              JOHN McCAIN, Arizona
MARY L. LANDRIEU, Louisiana          GEORGE V. VOINOVICH, Ohio
CLAIRE McCASKILL, Missouri           JOHN ENSIGN, Nevada
JON TESTER, Montana                  LINDSEY GRAHAM, South Carolina
ROLAND W. BURRIS, Illinois
EDWARD E. KAUFMAN, Delaware

                  Michael L. Alexander, Staff Director
     Brandon L. Milhorn, Minority Staff Director and Chief Counsel
                  Trina Driessnack Tyrer, Chief Clerk
            Joyce Ward, Publications Clerk and GPO Detailee


 AD HOC SUBCOMMITTEE ON STATE, LOCAL, AND PRIVATE SECTOR PREPAREDNESS 
                            AND INTEGRATION

                        MARK L. PRYOR, Arkansas
DANIEL K. AKAKA, Hawaii              JOHN ENSIGN, Nevada
MARY L. LANDRIEU, Louisiana          GEORGE V. VOINOVICH, Ohio
JON TESTER, Montana                  LINDSEY GRAHAM, South Carolina
                     Donny William, Staff Director
                  Ryan Tully, Minority Staff Director
                       Kelsey Stroud, Chief Clerk













                            C O N T E N T S

                                 ------                                
Opening statement:
                                                                   Page
    Senator Pryor................................................     1

                               WITNESSES
                        Thursday, July 22, 2010

Robert J. Fenton Jr., Deputy Assistant Administrator for 
  Response, Federal Emergency Management Agency, U.S. Department 
  of Homeland Security...........................................     3
Kevin Yeskey, M.D., Deputy Assistant Secretary and Director of 
  Preparedness and Emergency Operations, Office of the Assistant 
  Secretary for Preparedness and Response, U.S. Department of 
  Health and Human Services......................................     5
Paul Cunningham, Senior Vice President, Arkansas Hospital 
  Association....................................................    14

                     Alphabetical List of Witnesses

Cunningham, Paul:
    Testimony....................................................    14
    Prepared statement...........................................    39
Fenton, Robert J. Jr.:
    Testimony....................................................     3
    Prepared statement...........................................    21
Yeskey, Kevin, M.D.:
    Testimony....................................................     5
    Prepared statement...........................................    27

                                APPENDIX

Statement submitted by CriticalCareRoundtable.org................    50

 
                      A REVIEW OF DISASTER MEDICAL
PREPAREDNESS: IMPROVING COORDINATION AND COLLABORATION IN THE DELIVERY 
                 OF MEDICAL ASSISTANCE DURING DISASTERS

                              ----------                              


                        THURSDAY, JULY 22, 2010

                                 U.S. Senate,      
             Ad Hoc Subcommittee on State, Local, and      
           Private Sector Preparedness and Integration,    
                    of the Committee on Homeland Security  
                                  and Governmental Affairs,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 10:05 a.m., in 
room 342, Dirksen Senate Office Building, Hon. Mark L. Pryor, 
Chairman of the Subcommittee, presiding.
    Present: Senator Pryor.

               OPENING STATEMENT OF SENATOR PRYOR

    Senator Pryor. I will go ahead and call the meeting to 
order. I want to welcome everyone and thank you for being here 
today, especially our panelists.
    I know that we have some Senators who could not attend 
today, but we are going to keep the record open for questions 
for a few days after the hearing. I will do a quick opening 
statement and then we will let you guys do your opening 
statements. I think we are limiting those to 5 minutes, so if 
you could keep those at 5 minutes each, that would be great. 
And then I will have some questions and I may get some 
questions from various Senate offices but otherwise, we will 
leave the record open and get you guys to follow up.
    We have two panels and I just want to welcome everyone here 
and thank you all for coming. Today, we are talking about the 
National Disaster Medical System, (NDMS), and I appreciate you 
all's expertise and you all's work in this program and to help 
this Subcommittee to provide some oversight here.
    Weakness in our public health and medical response 
capabilities have been highlighted in catastrophic events over 
the last decades, such as the September 11 terrorist attacks, 
Hurricane Katrina, and the H1N1 outbreak. To that end, Congress 
has enacted legislation to improve Federal medical preparedness 
and response efforts, such as the Pandemic and All Hazards 
Preparedness Act.
    I really believe that strong planning is the foundation for 
effective action, and I think last year we saw how our 
investments had mitigated the effects of the H1N1 outbreak. 
However, State and local entities continue to worry about the 
next severe health threat or event that could overwhelm the 
medical system, and they have a series of concerns. We will 
talk about some of those today.
    To begin addressing these uncertainties, today we will 
examine the National Disaster Medical System as a case study of 
Federal medical response efforts. NDMS, operated by the 
Department of Health and Human Services (HHS), partners with 
other Federal agencies and the private sector to provide 
medical services in response to emergencies and disasters. More 
frequently, NDMS sends teams of volunteer medical providers to 
areas affected by a disaster, and that is great. I think we 
need to be doing that.
    And on three occasions, NDMS has activated volunteer 
hospitals to ensure patients affected by a disaster are able to 
receive medical care services in an unaffected area. As 
hospitals were activated for the first time, we discovered gaps 
in our planning and faced newly identified challenges with the 
NDMS. I think this Subcommittee is very interested in closing 
those gaps and making sure that as we go forward, we don't see 
these problems on a continuing basis.
    Today, we will hear from Federal officials regarding 
medical preparedness and response efforts as it pertains to 
NDMS. That is our first panel. On our second panel, we will 
hear from the Arkansas Hospital Association and they will share 
the experiences of volunteer Arkansas hospitals that were 
activated in response to Hurricane Katrina and Hurricane Gustav 
and their suggestions on ways to improve NDMS.
    It is my hope that this hearing will provide a better 
understanding of our utilization of the NDMS and how we can 
learn from these experiences to improve medical response needs 
of those affected by disasters. I believe what we will learn 
today will not only strengthen the current program, but will 
serve as a model of disaster medical response efforts for other 
Federal, State, and local stakeholders.
    With all that said, let me go ahead and introduce our first 
panel, and our first witness is Robert Fenton. He is the Deputy 
Assistant Administrator for Response for the Federal Emergency 
Management Agency (FEMA). Mr. Fenton is responsible for 
coordinating and integrating Federal interagency all-hazards 
disaster planning and response operations. He also manages 
Emergency Response Teams and oversees Disaster Emergency 
Communications (DEC) programs.
    Our next witness is Dr. Kevin Yeskey. He is Deputy 
Assistant Secretary and Director of Preparedness and Emergency 
Operations of the Office of the Assistant Secretary for 
Preparedness and Response (ASPR), at the Department of Health 
and Human Services. Dr. Yeskey is responsible for managing the 
National Disaster Medical System and addressing medical 
response efforts to disasters and emergencies. Dr. Yeskey has a 
long history in working on a variety of disaster response 
positions within the government.
    So, like I said, if you can do your opening statements in 5 
minutes, that would be great, and then I will have some 
questions.
    Mr. Fenton, would you like to go first?

    TESTIMONY OF ROBERT J. FENTON, JR.,\1\ DEPUTY ASSISTANT 
   ADMINISTRATOR FOR RESPONSE, FEDERAL EMERGENCY MANAGEMENT 
          AGENCY, U.S. DEPARTMENT OF HOMELAND SECURITY

    Mr. Fenton. Good morning, Chairman Pryor. I am Robert 
Fenton, Jr., the Federal Emergency Management Agency's Deputy 
Assistant Administrator for Response. I am responsible for 
ensuring the delivery of coordinated disaster response 
operations, integrated Federal interagency all-hazards disaster 
planning and response operations, and managing the Disaster 
Emergency Communications programs.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Fenton appears in the appendix on 
page 21.
---------------------------------------------------------------------------
    As you know, States, not the Federal Government, have the 
fundamental authority for evacuations. The State or local 
governments may order mandatory evacuation or recommend a 
voluntary evacuation when a State or local government 
determines that evacuation is necessary. It may also request 
assistance from the Federal Government. Emergency mass 
evacuation is the movement of general population from a 
dangerous area due to the threat of occurrence of a natural or 
terrorist attack, including the movement of patients in health 
care facilities and individuals in the community who have 
medical needs. HHS is a key partner to FEMA in carrying out 
disaster medical evacuation activities.
    FEMA's support to and involvement in medical evacuation 
activities falls into four key areas, the first being 
preparedness. FEMA is helping prepare State and local 
governments to provide updated guidance for incorporating the 
evacuation planning into emergency operations plans, as well as 
providing technical assistance to facilitate evacuation 
planning. Many of FEMA's grant programs are used to support 
evacuation-related activities. For example, the Regional 
Catastrophic Preparedness Grant (RCPG) program promotes 
planning for both evacuation and reception of evacuees and 
emphasizes the need to work with potential host-State 
communities to develop agreements prior to the occurrence of 
incidents.
    The second area is planning. In partnerships with State and 
local governments, FEMA is developing Federal-level 
Catastrophic Disaster Response Plans that include evacuation 
and medical evacuation elements. This planning takes into 
account the need for a significantly higher level of response 
assets, the possibility of little or no advance notice or 
warning, and the need to rapidly respond with massive support.
    The third area is coordination of Federal support. During 
response and recovery operations, the interagency community 
through the National Response Framework's Emergency Support 
Functions convene at the national level to support regions and 
States by leveraging authorities, supporting resource 
allocations and decisions, addressing policy issues, and 
supporting operational planning efforts. Many Federal 
departments and agencies provide their own resources and 
expertise that are critical to life-saving operations.
    Supporting the local response and recovery process. The 
Stafford Act authorizes FEMA to direct other Federal 
departments and agencies to utilize their own resources in 
support of State and local assistance efforts. State and local 
governments may request resources from FEMA to address unmet 
needs. Through mission assignments, FEMA can task appropriate 
departments or agencies to provide support to the requesting 
governmental entity. In anticipation of or in response to a 
Presidential declaration or a major disaster or emergency, FEMA 
can issue mission assignments to support medical response and 
evacuation activities.
    Under Emergency Support Function (ESF) #8, NDMS can be 
mission-assigned to deploy to support the medical response 
activities of the State and local governments overwhelmed in 
disaster situations. FEMA, Health and Human Services (HHS), the 
Department of Defense (DOD), and the U.S. Coast Guard together 
have developed prescripted mission assignments that are 
specifically available to request medical support and other 
associated capabilities. ESF #8 alone has more than 20 
prescripted mission assignments available to cover a variety of 
health and medical issues. FEMA also administers a contract 
that can provide ambulance and paratransit services that can 
support patient and medical evacuations.
    The fourth area is our recovery programs. FEMA also 
provides assistance to State and local governments as well as 
the individuals and families through two recovery programs. 
Under the Public Assistance Program, when the Emergency Medical 
Service Delivery System within a designated disaster area is 
severely compromised or destroyed by a disaster event, FEMA may 
reimburse State and local governments and certain private 
nonprofits for the cost of extraordinary medical care and 
medical evacuation expenses. Assistance for emergency medical 
care and medical evacuations for disaster survivors from 
eligible public and private nonprofit hospitals and custodial 
care facilities may also be made available.
    Under Individual Assistance, FEMA may provide eligible 
disaster survivors with a full range of programs designed to 
help meet individual needs, including but not limited to 
individual and household grants for housing and other needs 
assistance, crisis counseling, disaster unemployment 
assistance, and SBA low-interest loans.
    Certainly in the future, major disasters or emergencies 
will seriously threaten and damage local medical facilities 
which will necessitate patient evacuation and transport to 
either a temporary facility or an existing facility with spare 
capacity. With the appropriate coordination of Federal agencies 
working together with States, local Tribes, and voluntary 
agencies, we can meet the great challenges presented to the 
public when medical mass evacuations are required.
    Thank you for the invitation to appear before you today to 
explain FEMA's roles and responsibilities in medical evacuation 
during disasters and I look forward to any questions that you 
may have today. Thank you.
    Senator Pryor. Thank you. Dr. Yeskey.

TESTIMONY OF KEVIN YESKEY,\1\ M.D., DEPUTY ASSISTANT SECRETARY 
 AND DIRECTOR OF PREPAREDNESS AND EMERGENCY OPERATIONS, OFFICE 
OF THE ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE, U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Dr. Yeskey. Good morning, Chairman Pryor. Thank you for the 
opportunity to discuss the National Disaster Medical System and 
the key role it plays in our Nation's response to disasters.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Yeskey appears in the appendix on 
page 27.
---------------------------------------------------------------------------
    NDMS remains one of the Nation's most significant Federal 
medical response resources. Conceived in 1981 as an evolution 
of the Civilian-Military Contingency Hospital System, NDMS is 
an interagency cooperative effort among HHS, the Department of 
Defense, Veterans Administration (VA), and the Department of 
Homeland Security (DHS) that has over 7,800 employees, 95 
response teams, and approximately 1,700 participating 
hospitals.
    HHS can activate the NDMS to provide aid to victims of a 
public health emergency or to be present at locations at risk 
of a public health emergency. In recent years, NDMS has been 
called upon to respond to hurricanes, earthquakes, floods, ice 
storms, and a variety of national special security events, 
including the 2009 Presidential inauguration. In 2010 alone, 
NDMS has deployed over 1,700 personnel.
    NDMS has three components that I will briefly discuss: 
Field medical care, patient movement, and definitive care.
    Field medical care is provided by Disaster Medical 
Assistance Teams (DMATs). In response to the Haiti earthquake, 
NDMS deployed over 1,200 personnel that began deploying within 
24 hours of the request for assistance.
    The second component of NDMS, patient movement, requires 
extensive collaboration with our partners. DOD has the lead for 
providing air assets for movement out of the affected area. 
FEMA provides ambulance transport for short-distance patient 
evacuation.
    The final component of NDMS is definitive care, the 
provision of inpatient hospital services in participating 
hospitals. Hospitals participate on a voluntary basis and agree 
to provide available beds when requested by NDMS. Patient 
distribution is coordinated with the States and localities.
    NDMS as an organization continues to evolve and improve as 
it learns from previous responses. Some of those lessons 
learned include the need to enable more rapid deployments, 
improve the provision of definitive care, reduce costs, and 
more effectively coordinate activities regarding the evacuation 
of victims, their tracking, and their return. We employed these 
and other lessons learned in our recent Haiti response, 
including the deployment of HHS Service Access Teams to serve 
as case managers for patients evacuated to NDMS hospitals.
    HHS greatly appreciates the contributions made by Little 
Rock, Arkansas, hospitals to the victims of Hurricane Gustav. 
The Arkansas Hospital Association has challenged us to do 
better. This collaboration is helping us achieve a higher 
standard of response. ASPR leadership met with the Arkansas 
Hospital Association three times, most recently in May 2010. 
ASPR staff have ongoing communications with the Arkansas 
Hospital Association and the Arkansas Department of Health.
    In our corrective action process, several issues were 
identified and changes have been implemented that should all 
but eliminate those problems from recurring. We are working 
with the Department of Veterans Affairs to determine if it 
would be suitable to place an HHS-staffed Federal Medical 
Station at the Little Rock VA Hospital, which would serve as a 
temporary medical facility for those patients who are ready for 
discharge but unable to return to home.
    HHS has also worked with Louisiana to establish a 250-bed 
Federal Medical Station in Northern Louisiana to serve as a 
temporary receiving facility for patients discharged from 
Arkansas hospitals if patients are unable to return to their 
home of record or starting location.
    We will deploy our Service Access Teams early to assist in 
the case management of NDMS-evacuated patients. As mentioned 
previously, we are awarding a standing contract that will make 
non-emergent medical transport available to return evacuated 
patients to their homes or other receiving facilities.
    Our improvements made to NDMS and the newly implemented 
efforts dedicated to improving patient return are based on a 
thorough process of evaluations and system modifications. We 
are confident that these changes will prevent recurrence of 
delays experienced by Arkansas hospitals in 2008. NDMS has been 
a national resource for over 25 years and we are committed to 
the continuous improvement that will enable NDMS to remain 
flexible and responsive to current and new public health 
threats.
    Thank you for the opportunity to testify this morning, and 
I am happy to answer any questions you may have.
    Senator Pryor. Thank you both, and Mr. Fenton, let me start 
with you. Really, this is for both of you, but I will start 
with you, Mr. Fenton.
    I know that in this circumstance, you get two Federal 
agencies. You have FEMA and HHS, and HHS is the lead agency for 
medical care, but FEMA is the overall coordinating agency for 
all emergency response. And so I guess my first question is a 
general one, and that is when it comes to the kind of roles and 
missions here, is FEMA clear on its appropriate role and how it 
interfaces with HHS and vice-versa? Do you guys have a good 
working relationship, or have you noticed that there are some 
overlaps or gaps that needs to change and that needs to be 
honed a little bit? Mr. Fenton.
    Mr. Fenton. Yes, sir. I do believe we have a very cohesive 
and a very good working relationship and team up on a number of 
issues as it relates to medical areas. I think, first, starting 
from a doctrine perspective, the National Response Framework 
outlines roles and responsibilities. The National Incident 
Management System is the architecture for how we come together 
and how it organizes us into a management system. When we 
respond, we not only both understand this system and its roles 
and responsibilities as outlined in there, but we also partner 
together in many planning activities throughout the year, from 
the national level down to the regional level. So in each one 
of FEMA's regional offices, there are Health and Human Services 
personnel that are down there working collaboratively at that 
level.
    And then in addition, FEMA also brings together the 
interagency body which Health and Human Services is a part of 
through the Emergency Support Function Leadership Group that 
meets monthly to discuss specific issues or planning issues, 
like a lessons learned refined processes and procedures or 
those kinds of things at the national level. Also, at each 
region, they have a Regional Interagency Steering Committee 
(RISC) that is doing the same thing to align State and local 
and Federal Government at that level.
    And then, in addition, there are a number of exercises that 
we do together throughout the year to look at the plans for 
developing, continue to assess them, evaluate them, and make 
sure that we are able to adequately respond. And I think that 
just the number of mission assignments that I have talked to 
you about, we have outlined--as we continue to work through and 
see lessons learned, we either amend them or develop mission 
assignments that give HHS clear guidance on what we expect from 
them during disasters and how those relationships work. So I 
think it is a good relationship and we continue to work at it 
and resolve issues.
    Senator Pryor. Good. I may have some follow-ups there in a 
minute----
    Mr. Fenton. Yes, sir.
    Senator Pryor [continuing]. But that is good. I would like 
to hear from Dr. Yeskey.
    Dr. Yeskey. Yes. I would reiterate what Mr. Fenton said 
about our very good collaborative and cooperative interactions 
that we have. We support the DHS and FEMA in the National 
Response Framework as the lead for Emergency Support Function 
#8 Public Health and Medical Services.
    We have Regional Emergency Coordinators in each of the 10 
HHS regions, which overlap with FEMA regions, and they are 
interactive with the FEMA regional offices and participate in 
planning exercises. As HHS develops its response playbooks, we 
bring in partners from the interagency to include FEMA and DHS 
to participate in the development of those playbooks.
    In responses, we have HHS liaison officers and the Joint 
Field Office that FEMA runs. We put liaison officers in the 
Operations Centers, the National Incident Command Center and 
the Regional Coordination Centers that FEMA manages. And then 
FEMA participates on all our ESF #8 calls that we have as we 
respond. So we think there are very good communications and it 
is not unusual for us to pick up the phone and call one another 
if there are glitches, and so we have that relationship, as 
well.
    Senator Pryor. Good. Well, that is encouraging.
    Let me ask about a little more about roles or missions, and 
I am not sure where the line is, but one of the challenges I 
think we will hear about from the second panel today, from our 
Arkansas witness, is that some things seem to go very well, 
good planning and preparation but maybe there were a few areas 
that didn't go so well and one of those would be discharging 
the patient or returning the patient back to their home area. 
Whose responsibility is that? Is that HHS's responsibility?
    Dr. Yeskey. HHS maintains the responsibility to return 
patients back to their home of record, and that is usually 
accomplished through a mission assignment from FEMA.
    Senator Pryor. OK. So there again, that is collaborative, 
as well, in terms of how that works. And also, when it comes to 
the hospitals and other medical professionals getting 
compensated for their services, is that more under HHS or under 
FEMA?
    Dr. Yeskey. That is more under HHS.
    Senator Pryor. Let me go ahead and ask about that, then. 
You probably are familiar and probably know a lot more about it 
than even I do, but there was maybe an outstanding balance, I 
guess you might say, a few hundred thousand dollars in our 
State. I understand you guys are working through this right now 
with Arkansas, and we appreciate that. But again, is that more 
on the HHS side or the FEMA side?
    Mr. Fenton. We mutually work together on these issues and 
we are taking from this, I think, in lessons learned, we are 
taking issues to mitigate this in the future. But FEMA has a 
Host State Evacuation Sheltering Policy (HSESP) to reimburse 
local and State governments that host evacuees and FEMA 
reimbursed through the State of Louisiana to the State of 
Arkansas funding for certain costs that would be eligible, some 
of those for providing non-congregate care sheltering for 
individuals released from hospitals.
    It appears that the mechanism to capture that would be from 
the hospitals to Arkansas to Louisiana and then we would 
reimburse it. It appears that a number of hospitals, we didn't 
have their information through that system, so now that we have 
been made aware of it, we have gone back and we are going to 
recapture any costs that are eligible underneath that system.
    In addition to that, and I think because there are two 
different streamlines of patients going to the hospitals, there 
is one set of patients coming through NDMS's system, through 
the mission assignment that we tasked HHS underneath their 
authority to evacuate patients from Louisiana, and then there 
are other patients that are moving through normal means, maybe 
from hospitals to hospitals. So we have one system that allows 
us to reimburse local and State governments for those costs, 
for those out-of-pocket costs for that. Underneath HHS, what we 
have done now is we are expanding their mission assignment to 
allow them to capture and support those costs so it doesn't 
need the extra coordination of the receiving State to be able 
to do that.
    I don't know if you want to add anything to that or not.
    Dr. Yeskey. Yes, just a couple of things, and again, we are 
working with FEMA on all those issues. Just understand, the 
NDMS reimbursement is that NDMS reimburses after private third-
party insurers and Medicare but before Medicaid. So if a person 
has other insurance, then hospitals in the MOU that they sign, 
they go to bill those insurers first before they come to NDMS. 
Now, if a person doesn't have insurance or is Medicaid-
eligible, or a Medicaid recipient, then NDMS covers the 
reimbursement ahead of those self-pays or Medicaid.
    Senator Pryor. And if I understand, part of what you are 
both saying is that this is an area that you are trying to 
address, the Arkansas specific situation----
    Dr. Yeskey. Yes, sir.
    Senator Pryor [continuing]. But also, it is a lesson 
learned area that you guys are working on to try to make sure 
it doesn't happen like this in the future, or at least that it 
is handled appropriately in the future, is that the 
understanding?
    Dr. Yeskey. Yes, sir, and I think what we are trying to do 
is prevent the delays in returning patients, and some of the 
things I outlined as far as having our case managers actively 
engaged so we know when patients are ready for discharge and we 
can get them discharged, looking at alternate facilities, so if 
there is a mitigating circumstance where they cannot be 
returned to their home of record--in 2008, it was Hurricane Ike 
that was coming through Louisiana and Texas--we want to have 
the ability to have other outlets so the hospitals don't have 
to hold onto those patients, making sure that we have a liaison 
officer in the State Emergency Operations Center (SEOC), if 
requested, so they can work through those details about how 
those patients are going out, making sure that those are 
implemented as well as having that contract in place with a 
medical transport organization to take patients back when they 
are ready to go back home.
    Senator Pryor. So it sounds like this is a lot more 
involved than just the two of you sitting down, because you 
have already referred to--like in that case, to the Louisiana 
Emergency Management People, the Arkansas Department of 
Emergency Management, and then the transportation company. 
There are probably a lot of--well, of course, the hospital, and 
there are a lot of other interested parties that are involved 
in this process.
    Do you feel like, for any of those hurricanes, Gustav, Ike, 
Katrina, do you feel like there was adequate planning and 
preparedness on this specific area, or is that part of the 
lessons learned is that you found some gaps, and obviously one 
of those might be the payment issue, but you found other gaps 
that you guys are addressing to make sure it won't happen in 
the future?
    Dr. Yeskey. Yes. I think we try and learn from every 
response that we do, whether it is an exercise or whether it is 
an actual response, and we have a corrective action process 
that we have implemented so we can try and learn from these 
lessons and prevent them from recurring. Some of these are very 
complex interactions, as you stated. But we think we are making 
a great deal of progress and learning from this and hope to be 
able to generalize what we learn from Arkansas to the rest of 
the system so it doesn't happen there or elsewhere.
    Mr. Fenton. I was just going to add that, I think as you 
outlined, there are a number of moving parts when you start to 
execute medical evacuations or evacuations of the general 
public, and FEMA has a number of things to prepare for 
Hurricane Gustav, as lessons learned from Hurricane Katrina, 
from issuing contracts to--we have a contract for ambulances, 
for paratransit, to developing plans, to funding a lot of 
planning at the local and State level, to issuing policies that 
we never had before that allow us to reimburse host States, to 
bring States together to sign agreements on how many personnel 
they can accept and exactly where you go and work on 
transportation resources and bringing in the Department of 
Defense to this and the U.S. Coast Guard and everyone else that 
has a capability that may benefit that.
    And so we took on a number of activities to prepare us for 
Hurricane Gustav and make sure that we could respond, but I 
think that the best laid plans never survive the first disaster 
and there are a number of lessons that we learned from there 
and we will continue to make progress to improve those or 
address any shortfalls within those.
    Senator Pryor. OK. Let me see. I was going to ask about, I 
believe it was you, Dr. Yeskey, mentioned that maybe one of 
lessons learned or part of the plan that you are working on now 
are these Federal Medical Stations, and you are talking about 
one in Northern Louisiana and maybe one in Little Rock. What 
does that mean exactly? I don't know who to direct the question 
to. OK, Dr. Yeskey.
    Dr. Yeskey. No, that is for me.
    Senator Pryor. And so how will those work, and 
logistically, what is that?
    Dr. Yeskey. Yes, sir. A Federal Medical Station is a 250-
bed capacity that can be modularized in 50-bed capacities, but 
the maximum capacity is 250 beds. We staff those with medical 
personnel and they can perform a number of different functions, 
anywhere from just providing basic primary care to patients, or 
in previous experiences, we have had our Federal Medical 
Stations providing care to critical care patients as we were 
looking for other facilities. So we usually have a staff of 
about anywhere from 60 to 100 medical providers in those 
facilities. We look for buildings of opportunity, so they don't 
come with--it is not really a field hospital, but we look for 
large spaces where we can set up our cots, put our equipment 
in, and then we can house those patients and take care of them 
in those facilities.
    Senator Pryor. So you just need a building with adequate 
space for you to modularize this and kind of build it as you 
need it?
    Dr. Yeskey. Yes, sir. It is space and sanitation, water, 
things like that, and then wrap-around services, as we call 
them.
    Senator Pryor. And where do you get the personnel to do 
that?
    Dr. Yeskey. We draw our personnel from the National 
Disaster Medical System for a large part of this. We also used 
the Commissioned Corps of the Public Health Service, one of 
their Rapid Deployment Force teams. They provide help. We also 
use our Federal interagency partners, such as Veterans 
Administration. We can task them to provide clinical personnel 
for those and have in the past.
    Senator Pryor. I have heard, and I don't know how accurate 
it is, that it may be difficult for a lot of Federal employees 
to actually serve on those response teams. Is that accurate, 
that because of the Federal regulations or Federal rules? Do 
you know?
    Dr. Yeskey. I don't know. It requires some administrative 
activity so that person doesn't--since if they are an NDMS 
employee, they get paid by NDMS for their salary. If a Federal 
employee who is already receiving a Federal paycheck wants to 
join a team and participate on a team, they have to get 
approval from their parent organization, and then if they want 
to get paid from NDMS, then they would have to take an 
administrative break in pay so they could do that. Otherwise, 
we would expect them to participate in that Federal 
organization as part of that Federal organization and our 
tasking to that organization to participate in our response.
    Senator Pryor. OK. I will have to think about that a little 
bit to think through if that is the right way to handle that, 
because it seems if the Federal Government has a lot of 
expertise, has a lot of people that have expertise that might 
be part of that team, I just wonder if there are maybe too many 
barriers for them to serve. But let me think through that. We 
may have some follow-up questions.
    And you mentioned the Federal Medical Station in Northern 
Louisiana, and did you say you are going to do one in Little 
Rock, as well?
    Dr. Yeskey. We are working with the VA on the suitability 
of putting one at the VA facility there. And again, if this is 
to take care of patients who are ready for discharge, it would 
be a small facility and require a minimal level of care that we 
would be able to staff that.
    Senator Pryor. Would you do that in other locations around 
the country?
    Dr. Yeskey. Sure.
    Senator Pryor. And I assume you just have to look at their 
list of disasters and potential disasters to know strategically 
where to plan on putting those, is that right?
    Dr. Yeskey. Yes, sir. As part of NDMS and the Patient 
Evacuation System, we have Federal Coordination Centers. There 
are 72 of them nationwide, and that is where we, in our plans, 
where we choose from to evacuate patients to. And then we have 
VA or DOD Federal Coordinating Center staff there who work with 
the local hospitals and public health and emergency management 
to arrange the transport from the receiving point of 
debarkation to the hospitals. So those are the cities that we 
choose from to use for evacuation.
    Senator Pryor. OK. Dr. Yeskey, I don't know if this should 
go to you, but I will direct it to you unless Mr. Fenton wants 
to jump in here. In his written testimony, I don't know exactly 
what Paul Cunningham is going to say here in a few minutes, but 
in his written testimony, he mentions that the instructions 
provided by FEMA usually, or maybe through HHS, as well, but 
the instructions provided from the government seem to be 
constantly changing and oftentimes confusing. I understand how 
the aftermath of a major catastrophe can be very confusing. I 
get that. But to me, that seems that planning would take care 
of a lot of that.
    Can you all evaluate how you did in terms of communicating 
to the hospitals and other medical providers during this very 
challenging time? And again, I don't know if that is for you, 
Dr. Yeskey, or for you, Mr. Fenton, but----
    Dr. Yeskey. I can take a first crack at that. I think it is 
clear that we try and communicate as much as we can and we try 
and make sure that the information is clear and gets to the end 
users, the people who have to implement the guidance or the 
communications that go out. We try, when appropriate, to have 
telephone calls with appropriate personnel, whether that is the 
hospitals or a State Health Department or emergency management. 
We have an ongoing presence in the region through our Regional 
Emergency Coordinators (RECs) that, hopefully in the planning 
process and the exercises have a presence there and can answer 
questions and can provide a unified HHS response to questions 
that are asked. We also have other organizations, like Centers 
for Medicare and Medicaid Services (CMS) and Food and Drug 
Administration (FDA) in the regions who have a presence there 
who can answer some of the technical aspects about those 
programs.
    It is clear that we didn't do as good of a job as we would 
have liked to have done and continue to try and work with the 
localities to improve our communications.
    Senator Pryor. Dr. Yeskey, before Mr. Fenton jumps in on 
that answer, and it looks like he wants to, but let me ask a 
quick follow-up to that specific thing, and that is when you 
set up your relationship with these hospitals and you want them 
to participate in this, I am assuming that there is some sort 
of Memorandum of Understanding (MOU), or, Memorandum of 
Agreement (MOA) or whatever you may call it, but I am assuming 
there is some written understanding between HHS and the 
hospitals, and I am assuming that comes from HHS, not from 
FEMA.
    Dr. Yeskey. Yes, sir.
    Senator Pryor. Is that in the form of a blanket agreement, 
where you have a standard form that they sign onto, in other 
words, maybe--I hate to say this phrase, but a one-size-fits-
all, or do you tailor that based on the specific needs or 
requirements or circumstances of that particular institution?
    Dr. Yeskey. The MOA is a standard form that all 
participating hospitals sign.
    Senator Pryor. Does every one fit every circumstance, 
though?
    Dr. Yeskey. I don't know the answer to that question, per 
se. I think that the form is general. It talks about 
obligations of--responsibilities of HHS, responsibilities of 
hospitals, etc.
    Senator Pryor. OK. Mr. Fenton, did you want to jump in on 
this idea of the communication, either between FEMA--actually, 
I heard it was between FEMA and the hospitals was changing and 
there was maybe contradictory information given at different 
times to different people, different meetings. Do you have any 
comments on the communication and kind of evaluate how you guys 
did on that?
    Mr. Fenton. I would just, I guess, offer that I think that 
anytime during a major disaster, communications, whether 
physical communications or just the ability of communications, 
seems to be the root of most issues. It is not that there 
aren't plans in place or people in place trying to take the 
right actions. And in the case of Hurricane Gustav, I think you 
look back and you look at Hurricane Katrina and a number of new 
policies, laws that were pushed into effect following Hurricane 
Katrina as part of the Post-Katrina Reform Act, and then those 
new laws causing new policies was a substantial amount of new 
information to get out, educate, and communicate and rebuild 
plans to allow us to do some of those things now that we have 
been given authority to do underneath that legislation.
    So, that could be some of the changes. Some of the other 
changes could be as we continue to look at areas that we never 
looked at before, like the policy I referred to that allows us 
to provide--host States to accept evacuation and us to 
reimburse them at 100 percent of the costs. In there, there is 
an agreement that the host State has to accept. They have to 
agree to give 10 percent of their shelter capacity to a State 
that is evacuating.
    And so there are a number of things that we continue, as we 
go to whether it is September 11, 2001, Hurricane Katrina, 
other events, and we see areas that we either in our planning 
or historically never had to deal with before, we are 
continuing to build the capacity to work through and provide 
assistance to those issues. And after Hurricane Katrina, it was 
build a better ability to evacuate and receive people. So I can 
only guess that some of that, maybe the new policies coming out 
and the ability to communicate those, educate those, train the 
whole Nation on what those are. I think we have done an 
effective job on doing that, but obviously we need to continue 
to do that and to be able to improve on that.
    Senator Pryor. Dr. Yeskey, let me ask you another follow-up 
question here about the NDMS and the overall response from 
hospitals that you are reaching out to. Are hospitals generally 
willing to do this? Are they generally agreeable to participate 
in the program?
    Dr. Yeskey. I think they are generally willing to 
participate in the program. Hospitals have certain requirements 
for accreditation that participation in NDMS helps satisfy. 
They get to do exercises. They get to perform mass casualty 
drills and things like that. So I think there are some 
intangible benefits for the hospitals participating in that.
    Senator Pryor. What are the biggest barriers, the biggest 
reasons why hospitals wouldn't want to participate?
    Dr. Yeskey. I think one may be unfamiliarity with all the 
details that goes into participation as an NDMS hospital. Some 
may have fears that it may become an involuntary agreement to 
participate as an NDMS hospital, or they may be tasked to do 
that. This is a voluntary system and certainly we would not 
force any hospital to take patients that they wouldn't. But 
those might be some of the reasons they would not want to----
    Senator Pryor. Do you have any areas of the country where 
you have a deficiency in hospitals, that you need more 
volunteers, more hospitals?
    Dr. Yeskey. I would have to go back and look at that, but I 
can get that answer for the record.
    Senator Pryor. Well, speaking of answers for the record, I 
have some more questions for our two panelists, but what I will 
probably do is just submit those for the record and I will 
bring up our second panel here in a moment.
    But do either of you two have something you want to say in 
closing, or is there any point that I----
    Mr. Fenton. I would just say, when you look at this very 
complex issue, whether it is FEMA or HHS, we are just part of a 
team, a team that includes State, local government, the 
hospital providers, and private entities and all those, and to 
make it work, it takes all those entities coming together and 
the communication involved in all those. It is FEMA's 
responsibility to coordinate against a broad spectrum, not just 
medical evacuations, but everything from evacuations of the 
general population to debris removal to life-saving to, you go 
on and on of all the things that happen when a disaster comes 
together.
    I think we continue to work at that. We continue to develop 
capabilities to local and State governments to improve the 
planning, to improve the education, training, and exercising, 
to continue to try to validate those and improve our 
capability, and we will continue to work toward those. So thank 
you for the opportunity to be here today.
    Senator Pryor. Thank you. Dr. Yeskey.
    Dr. Yeskey. Thanks for the opportunity to discuss NDMS.
    Senator Pryor. Well, thank you all for being here. I think 
we see this on this Subcommittee as just part of our general 
oversight. I think that everybody's heart is in the right 
place, trying to do the right thing. We just want to make sure 
our system works well, and the preparedness and the planning 
just works the way it should, because in a crisis, you don't 
have time to think through that. I am sure in any given crisis, 
no matter when or where, nothing works 100 percent of the time 
exactly the way you wanted it to go, but I think--it sounds 
like you guys have identified some areas that we need to focus 
on and it sounds like you guys are focusing on those.
    So again, we may have some follow-up questions for you, but 
I do want to thank both of you for being here today and I will 
go ahead and dismiss you all and we will bring up our second 
panel. So thank you for being here.
    As the staff here is switching out the table, I will go 
ahead and introduce our second panelist today. I want to 
welcome Paul Cunningham, who is from Arkansas and is a Senior 
Vice President at the Arkansas Hospital Association. He is 
responsible for policy analysis, Federal relations, and 
reimbursement issues for the Arkansas Hospital Association. Mr. 
Cunningham will speak to the experience of Arkansas volunteer 
hospitals that were activated under NDMS. He brings a lifetime 
of experience to this equation and this conversation and we 
appreciate you being here today and appreciate the work that 
your association does.
    I want you to give your opening statement, but if you can 
remind me how many members you have in your association. How 
many member hospitals are there?
    Mr. Cunningham. We have 104 member hospitals in the 
association.
    Senator Pryor. Go ahead with your opening statement, 
please.

    TESTIMONY OF PAUL CUNNINGHAM,\1\ SENIOR VICE PRESIDENT, 
                 ARKANSAS HOSPITAL ASSOCIATION

    Mr. Cunningham. Thank you, Mr. Chairman. I am Paul 
Cunningham, Senior Vice President of the Arkansas Hospital 
Association in Little Rock, Arkansas.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Cunningham appears in the 
appendix on page 39.
---------------------------------------------------------------------------
    I am here today speaking on behalf of a dozen hospitals 
located in and around the metropolitan Little Rock area which 
were, until June 1 of this year, participants with the National 
Disaster Medical System. They were also part of the only 
activations of civilian hospitals in NDMS's 25-year history for 
the combination of patient evacuation and definitive medical 
care purposes following disasters that occurred on U.S. soil. 
During their activation in late August of 2008, prior to the 
landfall of Hurricane Gustav, our hospitals identified several 
problems with the system. We have been working since then to 
resolve those issues, but with limited progress.
    During the activation 2 years ago, Little Rock hospitals 
received and cared for 225 patients who were included in the 
evacuation from Hurricane Gustav in Southern Louisiana. They 
continued caring for many of the patients for nearly a month, 
and in some cases more, waiting for Hurricane Gustav and then 
Hurricane Ike to clear the area, allowing the returning of 
patients to their home State. During the activation, it became 
clear that the NDMS Memorandum of Agreement with hospitals 
needs to be revised to make the program more viable for similar 
events in the future, wherever they might occur in the country.
    Efforts to get our concerns addressed date back to late 
September 2008, and more than a year has gone by since we first 
notified HHS about the need for changes in the agreement. 
Delays in getting that needed attention prompted Little Rock 
hospitals to withdraw their participation effective June 1 of 
this year. We want to point out that there has been progress 
made in the past few months working with the ASPR, Dr. Nicole 
Lurie, and Dr. Kevin Yeskey, and yet we are disappointed that 
there has been no specific action to address our proposed 
revisions to the agreement that were submitted in June 2009.
    Our hopes were that at least some of the changes could be 
incorporated before the 2010 hurricane season began last month. 
They were not. We believe the same concerns could later prove 
to be a barrier that will hold back hospitals in other States 
from participating, as well, limiting NDMS's capabilities in 
the future.
    A key change involves getting patients back to their home 
States following an evacuation. At this time, the agreement 
doesn't speak to the return of patients. Although the Air Force 
is directly involved with evacuation of patients from a 
disaster area to a host State, it is not an available NDMS 
resource for getting those same patients back to their home 
States or to the original transferring hospital. Private 
contractors must be used.
    Delays in getting the contractor ready to transport 
patients and the inability to return them in a timely manner 
created a number of problems. Those included extended hospital 
stays, the need to feed and to shelter some patients who could 
be discharged, and their families if they were there, and to 
transport other patients back to Louisiana. All of that was 
done at the hospitals' own expense.
    Local patients were also affected by having to postpone or 
delay elective procedures because beds or staffing in those 
hospitals were not available due to the demands of the 
evacuated patients.
    Another problem stems from reimbursement limits imposed by 
Medicare payment policies. Those alone govern hospitals' 
reimbursement for care provided to Medicare patients who are 
caught up in these evacuations. The agreement offers a fair 
approach to helping pay for the care for uninsured patients and 
Medicaid patients and even some insured patients, but Medicare 
patients are left out. NDMS offers no reimbursement for them. 
They are simply Medicare's responsibility.
    The policy fails to understand and to adjust for the 
idiosyncracies of Medicare's rules, especially those involving 
patient transfers and limits on covered day. Whatever Medicare 
reimburses is full payment, regardless of the extenuating 
circumstances. NDMS's unique Federal-State partnership 
shouldn't create such obstacles to hospitals' participation. 
However, it does just that.
    The Little Rock hospitals have withdrawn from NDMS 
participation for now, but we believe there are broader 
implications. Most immediate will be the cost of evacuations 
from the Louisiana Gulf Coast to locations further away than 
Little Rock in the event of another hurricane. NDMS also stands 
to lose the experience in such patient movements that is 
available with the Little Rock hospitals, and they were highly 
praised for their work during the Hurricane Gustav event.
    While losing 12 hospitals in Arkansas may seem 
insignificant to a program with over 1,800 participating 
volunteer hospitals nationwide, it is very possible that 
hospitals in other States might also later decide to withdraw 
their participation if the changes to the agreement are not 
made. That could severely limit NDMS's abilities to respond to 
disasters in the future.
    We want to thank you for the opportunity to be here and to 
speak on this today and certainly will answer any questions 
that you have.
    Senator Pryor. Thank you very much, and let me go ahead and 
jump in. You mentioned that the Little Rock area hospitals have 
withdrawn from NDMS, at least for now, until some changes are 
made in the system. Of course, that concerns me about the 
overall integrity of the system, if you guys feel like it is 
just not a workable situation. But what sort of changes are you 
all suggesting to the Memorandum of Agreement?
    Mr. Cunningham. We would like something in the agreement 
specifically regarding the repatriation or the return of 
patients from a host State to their home State. We would like 
to have those agreements in place, authorized, and signed prior 
to the event actually occurring. We would also like to see 
something in the plan regarding the establishment of Federal 
medical shelters, where patients who can be discharged have a 
place to go. In the case of Hurricane Gustav and then Ike as it 
came ashore later, we had patients from Louisiana who were 
ready to be discharged but who literally had no place to go.
    Senator Pryor. Right. OK. And also, you mentioned Medicare 
in----
    Mr. Cunningham. Medicare is a very distinct problem. Under 
the NDMS agreement, Medicare is responsible for paying for care 
provided to Medicare patients, who again are caught up in these 
patient evacuations. That presents a problem on a couple of 
fronts. First is Medicare's policy regarding transfer of 
patients. Now, normally, if a patient is transferred from 
Hospital A to Hospital B, the transferring hospital gets a per 
diem, not the full Diagnosis Related Group (DRG) amount, and 
the receiving hospital does get the full DRG amount but then 
can discharge the patient.
    In evacuations such as this, the patient actually goes from 
Hospital A to Hospital B and then theoretically back to 
Hospital A. Well, in a very short transfer, that doesn't 
present a real problem because the payment is made under 
arrangement. The transferring hospital and the receiving 
hospital agree to a payment.
    In the case of Hurricanes Gustav and Ike, we found our 
patients having to stay very lengthy periods. Some patients 
were in the hospitals for 30 days or more. If you look at just 
the DRG limit--and let me make a clarification that in 
November, and this was sometime after the event itself, HHS did 
agree that those patients at hospitals in both States could 
bill those patients the full DRG amount. But that is not an 
overall umbrella policy. That policy has to be made on each 
individual event, such as if something else happened this year 
or next year, HHS would also have to say that policy was in 
place for that event, too. It is not an overall policy.
    But the length of stay under the Medicare DRG system puts 
patients at a point where if they cannot be discharged--if they 
are ready to be discharged and cannot go anywhere, well, that 
is now considered medically unnecessary care. Medicare does not 
pay for medically unnecessary care, regardless of the 
extenuating circumstances. So our hospitals were left having to 
keep some patients who had no place else to go for lengthy 
periods of time without any Medicare reimbursement.
    Senator Pryor. Yes. I was going to follow up on that. So I 
am sure--I don't know how many patients came up during those 
hurricanes----
    Mr. Cunningham. Well, there were 225 total----
    Senator Pryor. Two-hundred-and-twenty-five.
    Mr. Cunningham. I can't tell you how many were uninsured or 
Medicare or whatever, but 225.
    Senator Pryor. I am sure there are different circumstances 
on every single one----
    Mr. Cunningham. Exactly.
    Senator Pryor [continuing]. But am I correct in my 
understanding that some of them stayed in the hospital in the 
Little Rock area not because they needed the medical services 
anymore, because they just didn't have anywhere to go?
    Mr. Cunningham. That is correct.
    Senator Pryor. And that does present all kinds of problems.
    Mr. Cunningham. Absolutely.
    Senator Pryor. I mean, obviously, that is the least 
efficient place you want to have someone.
    Mr. Cunningham. In addition just to the payment problems 
themselves, it created problems for local patients who had to 
postpone or delay elective procedures or admissions because 
staffing was needed to take care of the patients who were here 
from Louisiana.
    Senator Pryor. Out of the 225, do you know how many would 
fit into that category that they really had no more need for 
medical services, but because they just didn't have anyplace 
else----
    Mr. Cunningham. Senator, I don't have that information. We 
could probably get it for you, but I don't have it right now.
    Senator Pryor. And it sounds like you are still in 
discussions with FEMA and HHS----
    Mr. Cunningham. That is correct.
    Senator Pryor [continuing]. To try to get this resolved.
    Mr. Cunningham. We are working with Dr. Yeskey. We have 
been trying to resolve some of these issues. But as of June 1, 
and this was not an easy decision for our hospitals, we feel 
like there were still enough concerns out there that merited 
their withdrawal from the system until a more definite plan of 
action, more written plan of action could be presented to us.
    Senator Pryor. I am not trying to put words in your mouth, 
but I am curious about your impression of this. Is that because 
the two agencies are being inflexible, or is it because you are 
dealing with two or more Federal agencies and it just takes a 
long time for them to make a decision?
    Mr. Cunningham. I think your second assessment would be 
correct. I think it is just a complicated situation that could 
probably be improved with some additional work, some closer 
ties, and it sounds to me from the previous presentation like 
both agencies are working on that.
    Senator Pryor. And have they told you that they are willing 
to make some changes to the MOA?
    Mr. Cunningham. They have indicated a willingness, but we 
have yet to see something in writing to the point that our 
hospitals feel comfortable enough that they would not be in the 
same situation, let us say, if a hurricane were to hit this 
year as they were when Hurricanes Gustav and Ike hit in 2008.
    Senator Pryor. And I don't know the working definition for 
everyone on what is medical care versus other----
    Mr. Cunningham. Exactly.
    Senator Pryor [continuing]. Type of services that you 
provide, but give us a sense of things that you did for these 
patients that wouldn't be necessarily considered medical care. 
And I can think of a lot, but I am curious about what some of 
those might be.
    Mr. Cunningham. Well, there were occasions, and we did work 
closely with the Arkansas Department of Health on this. If 
there were patients in the hospitals who were ready to be 
discharged and who did not have a way to get back to Louisiana, 
for instance, our hospitals worked in conjunction with the 
Health Department to try to find places, such as local hotels 
where they could put these people up for several days. They 
found themselves in a need to both feed patients and families 
if families had come with them, that sort of thing.
    There were two hospitals that we are aware of who actually 
took it on themselves to take patients who were ready for 
discharge and transport them on their own back to Louisiana. 
Those are all non-medical costs and certainly are not the 
responsibility of the NDMS, but it would be good if, again, a 
closer tie between NDMS and FEMA, if there could be some 
agreement where we felt confident that in those cases where 
hospitals do have to provide non-medical care, that there was 
an avenue for reimbursement.
    Senator Pryor. It seems to me that you don't really get 
compensated for that non-medical care unless FEMA has----
    Mr. Cunningham. Unless FEMA has a way to do it, we do not. 
That is correct.
    Senator Pryor. But it seems to me that they ought to 
consider that compensation, because most of those patients 
wouldn't have that except for these circumstances, right?
    Mr. Cunningham. That is true, and there were extenuating 
circumstances here. We had a situation where we had Hurricane 
Gustav come on shore, and then about 2 weeks later Hurricane 
Ike came on shore.
    Senator Pryor. Right.
    Mr. Cunningham. And you might think that this is a very 
unlikely scenario, but we would like to point out that in 2005, 
you had Hurricanes Katrina and Rita that came on shore very 
closely together, too. So it can happen and it has happened 
twice in the last 5 years.
    Senator Pryor. Let me ask you about something I think was 
in your written testimony--you maybe said it a few moments 
ago--but about the communication between FEMA and your local 
hospitals. My understanding is that there was some confusion, 
maybe contradictory information----
    Mr. Cunningham. Well, it was very confusing. I know that we 
at the Hospital Association, along with most of our 
participating hospitals, were on daily calls with FEMA and NDMS 
about what exactly do we need to do? What is the process? When 
is the transport contractor going to be in place? How soon can 
they transport patients back? How long will that take, things 
like this. And there were many occasions where you literally 
got different information every day.
    Senator Pryor. And do you know why you were getting that? I 
mean, is that because maybe FEMA and/or HHS hadn't coordinated 
or they just hadn't thought through all the details?
    Mr. Cunningham. Probably that. I guess for Arkansas, at 
least, the first case of this magnitude. I don't know what may 
have happened after Hurricanes Katrina and Rita. We did get a 
few patients in Arkansas. I think a lot of those went to other 
States. But regardless, the process of getting patients into 
the State into hospitals went very smoothly. The process of 
getting them out did not, and it may be that this is just 
something that we need to put more effort in, more planning, 
more practice, things like that.
    Senator Pryor. Again, not trying to put words in your 
mouth, but it sounds like what you are saying is that NDMS is 
something that we should continue, that it is important in a 
time of crisis----
    Mr. Cunningham. Absolutely.
    Senator Pryor [continuing]. But it also needs to work well, 
and hopefully, lessons learned here would be some of the 
experience that the hospitals in the Little Rock area had that 
we just need to make sure these don't happen again, and 
hopefully you can get compensated for some of the things you 
did now. Is that fair to say?
    Mr. Cunningham. Yes. I think, absolutely, you are correct. 
NDMS is a valuable resource. We need it to respond to emergency 
disaster events wherever they occur in the country. I think it 
is also set up and it is needed to take in civilian and troop 
casualties that might occur from conventional wars in other 
places or to respond in the event that somebody would actually 
use a weapon of mass destruction in the country, not to mention 
things like H1N1. So it is very valuable. We want it to work. 
We want to be a player in it. We just feel like some changes 
are needed before we feel comfortable in making that step.
    Senator Pryor. Yes, and I am not critical of your decision 
to get out of it, at least temporarily, because given your 
experience, it is understandable. But it does concern me that 
it is sending a signal to other hospitals around the country--
--
    Mr. Cunningham. Exactly.
    Senator Pryor [continuing]. To be careful before they sign 
onto something like this, because it is not as smooth as you 
might think on the front end.
    Mr. Cunningham. And I think if Arkansas hospitals continue 
to be out and are out if something else occurs, then that puts 
the evacuation to another city even further away from the Gulf 
Coast, the Louisiana Coast, in particular, than Little Rock. 
For instance, Oklahoma City would be the next city, is my 
understanding. That is about an additional hour's flight to 
shuttle patients back and forth. If they were to leave, it 
could be El Paso, Texas, could be another city. But yes, there 
are some Federal costs involved here, too.
    Senator Pryor. Right. Well, thank you for your statement. 
Thanks for answering the questions. Thanks for coming up here 
for this. Did you have anything you wanted to say in closing?
    Mr. Cunningham. I wanted to say that we certainly 
appreciate the opportunity to come and to review these concerns 
with you.
    Senator Pryor. Well, thank you for being here and thank you 
for your efforts. First, thanks for participating in the 
program and taking care of people. That is important. 
Hopefully, you will be the sort of catalyst for getting things 
worked out in the future to improve the program over time.
    What we are going to do is we are going to leave the record 
open for 15 days, so it is very possible that other Senators 
and other offices will submit questions, if you would work with 
staff to try to get those answers back to us.
    I again want to thank you and thank all our panelists for 
being here and participating in this.
    With that, we will adjourn the hearing. Thank you for doing 
what you do.
    Mr. Cunningham. Thank you.
    [Whereupon, at 11:06 a.m., the Subcommittee was adjourned.]



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