Ten years have passed since the U.S. was attacked on September 11, 2001, and six since Hurricane Katrina slammed into the Gulf Coast. While disasters of this magnitude are rare, hundreds of smaller-scale disasters occur every year, including tornadoes, blizzards, fires, earthquakes, airline crashes, and chemical spills.
Whether confined to your building or involving your entire community, any unforeseen event could constitute a disaster for your rheumatology practice, according to Owen J. Dahl, president of Owen Dahl Consulting in The Woodlands, Tex., and author of the eBook The Medical Practice Disaster Planning Workbook (Greenbranch Publishing, 2009). The unexpected force and unusual path of Hurricane Irene was a wake-up call for residents of the Northeast and New England, but consider the impact of a lightning strike that ignites a structural fire, a speeding car that plows into a building, or a shooting that turns a business office into a crime scene.
Although there’s a difference between anticipated disasters, such as hurricanes, and unexpected events, “everyone is at risk,” insists Madelaine Feldman, MD, a rheumatologist and partner with Wilson, Sanders & Feldman in New Orleans who weathered the effects of Katrina.
Two reports, “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations,” issued by the Institute of Medicine (IOM) in 2009, and “A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies,” prepared by the U.S. Department of Health and Human Services in 2007, highlight the need for healthcare organizations to plan proactively.1,2
Table 1: Flight File
Supplies and equipment inventory
- Itemize inventory and include serial numbers
- Photograph or videotape the office, supplies, and equipment
Insurance policies and business contracts
- Copies and the original of each insurance policy
- Up-to-date listings of insurance companies, policy numbers, and agent phone numbers
- Copies and original of other contracts, including leases, managed care contracts, and service contracts
Documents, licenses, diplomas, and numbers for physicians and staff
- Originals and duplicates of Drug Enforcement Agency licenses, state medical licenses, business licenses, credentialing information (diplomas, medical school, residency, fellowship), board certifications, resumes, and continuing medical education records
- Federal employer numbers, national provider identifier numbers, and provider numbers
- Malpractice insurance face sheet
Patient records and information
- Patient list or patient backup files
- Office forms scanned to digital or hard copies Emergency contact information
- Home and cell phone numbers and contact numbers of out-of-town relatives for all physicians and staff
- Contact numbers for colleagues in the ACR or Coalition of State Rheumatology Organizations
- Cell phone with texting capability, BlackBerry, or satellite phone
- Remote phone site and website
- Contact numbers for the group’s attorneys, accountants, bankers, managed care companies, and insurance agents
Financial
- Names and account numbers of all bank and financial accounts and payroll files
- Tax information, including copies of documents filed with the Internal Revenue Service
Source: Madelaine Feldman, MD, Wilson, Sanders & Feldman, New Orleans.
Reprinted with permission.
A disaster plan provides a rheumatology practice with a template to maintain or restore business operations, no matter what the crisis. Whether you start small and add a piece to the plan each month or schedule a retreat to draft the entire plan in one sitting, it is essential to distribute the plan to every employee and review and revise it regularly—when you change clocks in the spring or fall, for instance.
“Practices at risk of hurricanes could review the plan the last week of May, while those at risk of tornadoes could review it in February,” Dahl suggests. “But every practice should pick a date and put it on the calendar.”
Put People First
Rheumatologists first should consider the role they might play following a disaster, says Jane El-Dahr, MD, head of the section of pediatric allergy/immunology/rheumatology at Tulane University School of Medicine in New Orleans. The extent of their direct involvement depends on the type of event, size of the group and whether the physicians practice in a freestanding office, hospital-based clinic, or university setting. Rheumatologists typically take a supporting role to critical care specialists and surgeons in the wake of a disaster unless patients must be seen in outpatient clinics.
“You’ll have to handle at least basic primary care issues—not just rheumatology—during a widespread disaster,” Dr. El-Dahr says.
The welfare of family, staff, and patients is the next priority in disaster planning, so communications are key. Compile emergency phone numbers for physicians, staff, and patients, including contact numbers for their nearest out-of-town relatives. Create a detailed phone tree and store it in a secure location.
“Many rheumatology patients have disabilities, so make sure they have basic information about government services,” Dr. Feldman says, suggesting the list include telephone numbers for the Red Cross, Alzheimer’s Association, and local Council on Aging.
Similarly, rheumatologists should advise patients to keep an “evacuation kit” in a waterproof bag with a list of their medications, the doses of each, the date of their last refill, and the contact information of their retail or mail-order pharmacy.
“Katrina was not just a disaster that came and went,” Dr. El-Dahr points out. “The entire city shut down, and we had no power for months. Patients scattered all over the country. One way we found patients was to track their location when they refilled their biologic medications.” Passing such information to prescribing physicians does not violate the Health Insurance Portability and Accountability Act, she adds.
Develop an Integrated Strategy
Use your website as a message board where you can post updates about office hours and provide contact information for staff and patients, Dahl suggests. Use text messages or create an online chat group in a secure area of your website to distribute schedules and arrange meetings. Notify media contacts at the local television station, radio station, and newspaper about the status of your office.
“You’ll need to let staff know when to report to work, where to report, and what or whether to expect payroll,” says Bill Stewart, MHA, director of operations for Northwest Diagnostic Clinic in Houston, Texas. “Your patients will want to know if they have an appointment, how they can get their prescriptions refilled, and what to do about their infusions.”
In the event of a regional disaster, you’ll need an integrated strategy that might include a combination of landlines, voice over Internet protocol (VoIP) access, remote toll-free numbers, and walkie-talkies, Dahl points out. Ensure that physicians and key staff members have car chargers for their cell phones in case power lines go down, and consider adding a satellite phone to your emergency equipment in case cell towers are down.
Consider Tools and Equipment
Next, examine the potential impact of a disaster on your equipment and inventory. For insurance purposes, maintain an updated record of medical and office equipment. Keep a running inventory of supplies, including refrigerated drugs that may represent an investment of hundreds of thousands of dollars. Following a disaster, you may need to discard many supplies because of contamination risk.
“Rheumatology practices with infusion suites need to pay special attention to their refrigeration,” Stewart says. “Due to the cost of these drugs, investing in external temperature probes is money well spent.” An IT vendor can integrate these into the group’s electronic network and even generate an email to someone in the practice when the temperature rises or falls beyond a certain threshold, he adds.
If your practice is housed in a dedicated building, consider purchasing a propane generator for emergency power, suggests Kenneth T. Hertz, a principal consultant in the MGMA Health Care Consulting Group who is based in Alexandria, La. If you’re located in a flood zone, install the generator on the roof of your building.
Consider developing a reciprocal arrangement with a rheumatology practice on the other side of town or in a neighboring community, Dahl adds. In the event one practice is damaged or destroyed, those rheumatologists can temporarily use the other practice as a patient care center, treating their patients after hours and on weekends until their office is repaired or reestablished. “You don’t know which side of town might be affected by a disaster, so both groups must be open to the idea,” Dahl says.
Also anticipate the impact of a disaster on your support services. If your bank floods, how will you manage accounts payable? How will you process your accounts receivable and daily deposits? What’s your backup plan if you lose access to your lockbox? If mail service is disrupted, how will patient payments be routed to your practice? If you change locations, even temporarily, how will financial institutions and vendors find your office? Your disaster plan should address these issues.
“After Katrina, it took months—years, in some cases—to reestablish the financial and postal connections,” Dahl notes.
Although business interruption insurance saved some practices in New Orleans following Katrina, some physicians who didn’t pay themselves a salary after the hurricane negated their policies.
Back Up Critical Documents
Ensure that you’ll have access to patient and financial information if your physical plant is damaged or destroyed. Secure a copy of the network schematic of your hardware, as well as software disks and documentation, so you can restore the system if your network crashes, Hertz suggests.
Back up your electronic medical record (EMR) or clinical and billing data at least weekly—preferably daily—and store the information on a remote server, preferably in another state. An on-site server or backup tapes will be of no value if your practice burns to the ground or washes away.
Dr. Feldman’s practice did not use an EMR prior to Katrina. Afterwards, “literally, everything was gone,” she says. “I’m still getting Social Security disability requests for those records, and they just don’t exist.”
Dr. Feldman also recommends the creation of what she calls a “Flight File”—a compilation of insurance policies, service contracts, leases, warranties, patient records, vendor contacts, and other vital documents containing information that would enable the practice to remain solvent and rebuild in the event of a total loss (see Table 1). Store copies of these documents offsite, either in hard copy or on a flash drive, and update them quarterly, she suggests. Develop a chain of command for transporting the original Flight File in a waterproof, fireproof box in the event of an emergency.
“If you prepare a Flight File and keep a copy offsite, you’ll have the basics with you,” Dr. Feldman says. “When you lose everything and you’re in survival mode, you need every piece of information at your fingertips so you don’t have to try to remember details.”
Once your disaster plan is complete, laminate copies of the basic steps and place the template throughout your office, including the physician and staff lounges, so the information becomes ingrained.
Finally, purchase business interruption insurance to cover your operating profit, salaries, and fixed expenses if your operations are curtailed or suspended during an insured loss. A rider called “extra expense coverage” would pay for the cost of rental space, enabling your practice to remain whole following the loss.
Like most insurance policies, business interruption insurance may include a waiting period, deductible, and limitations based on how the policy defines a disaster. Read the fine print. Although business interruption insurance saved some practices in New Orleans following Katrina, some physicians who didn’t pay themselves a salary after the hurricane negated their policies.
In any event, don’t make your insurance policy your primary disaster plan, Stewart advises. “It’s always best if you can prevent as much of the loss as possible,” he says.
Marie Powers is a journalist based in Georgia.
Include Managed Care Contracts in Your Disaster Plan
During an emergency, medical practices must maintain payer contracts so they can continue to bill for the clinical services they provide. If physicians are caring for victims or if the practice site has suffered devastating physical damage, meeting the administrative requirements of your managed care agreements will be a low priority. As the community returns to normalcy, however, those details could create new burdens for your practice, according to James G. Fouassier, Esq., associate director in the department of managed care at Stony Brook University Hospital in N.Y.
If the federal government declares your community a disaster area, the Centers for Medicare and Medicaid Services may issue a waiver relieving healthcare providers of certain documentation and technical submission requirements for claims related to Medicare and Medicaid, Fouassier says. However, there’s no guarantee that the government will take this action, and private payers won’t necessarily be obligated to do the same. By adding language to your managed care contracts to address disaster scenarios, you can require payers to reimburse services, even if you’re temporarily forced to suspend standard billing practices.
Here are several strategies Fouassier suggests:
- Address the topic during contract negotiations, seeking to include language that defines precisely when a disaster or emergency is considered to have occurred. The usual description refers to an official declaration by a government agent or authority, but you should press for more limited situations in which an isolated incident, such as an explosion, destroys or seriously damages the building containing your practice. “Contract language shouldn’t be so specific that it can’t be flexible,” Fouassier advises.
- Require that contract language related to disasters suspends specific time frames and formats for claims submission. Your physicians won’t have time to document during an emergency, so you’ll likely face problems coding those claims properly. Ask commercial plans to accept any government accommodation that affects Medicare or Medicaid.
- Seek relief from requirements for preauthorization or notification for admissions, treatment, and discharge and request suspension of concurrent utilization reviews. Although it’s reasonable for payers to ask for some evidence of medical necessity once the disaster has ended, seek language that allows alternatives, such as physicians’ affidavits or copies of X-rays.
- Don’t be dissuaded if a payer claims that you’re protected by a standard force majeure clause, which typically states that the contract doesn’t anticipate war, natural disasters, and other “acts of God.” Given the lessons of 9/11 and Hurricane Katrina, combined with this year’s unusually severe weather events, practices are hard pressed to argue that they could not anticipate virtually any large-scale disaster, Fouassier says.
References
- Institute of Medicine. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations. September 2009. Available at www.iom.edu/Reports/2009/DisasterCareStandards.aspx. Accessed September 15, 2011.
- U.S. Department of Health and Human Services. A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies. September 2007. Available at www.phe.gov/Preparedness/planning/mscc/handbook/Documents/mscc080626.pdf. Accessed September 15, 2011.
