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The American Journal of Managed Care January 2015
Disease-Modifying Therapy and Hospitalization Risk in Heart Failure Patients
Fadia T. Shaya, PhD, MPH; Ian M. Breunig, PhD; and Mandeep R. Mehra, MD, FACC, FACP, FRCP
Frequency and Costs of Hospital Transfers for Ambulatory Care-Sensitive Conditions
R. Neal Axon, MD, MSCR; Mulugeta Gebregziabher, PhD; Janet Craig, PhD, RN; Jingwen Zhang, MS; Patrick Mauldin, PhD; and William P. Moran, MD, MS
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A. Mark Fendrick, MD, and Michael E. Chernew, PhD Co-Editors-in-Chief, The American Journal of Managed Care
Value-Based Insurance Design: Benefits Beyond Cost and Utilization
Teresa B. Gibson, PhD; J. Ross Maclean, MD; Michael E. Chernew, PhD; A. Mark Fendrick, MD; and Colin Baigel, MBChB
Changing Physician Behavior: What Works?
Fargol Mostofian, BHSc; Cynthiya Ruban, BSc; Nicole Simunovic, MSc; and Mohit Bhandari, MD, PhD, FRCSC
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State of Emergency Preparedness for US Health Insurance Plans
Raina M. Merchant, MD, MSHP; Kristen Finne, BA; Barbara Lardy, MPH; German Veselovskiy, MPP; Casey Korba, MS; Gregg S. Margolis, NREMT-P, PhD; and Nicole Lurie, MD, MSPH
Revisiting Hospital Length of Stay: What Matters?
Mollie Shulan, MD; and Kelly Gao
Medical Homes: Cost Effects of Utilization by Chronically Ill Patients
Jason Neal, MA; Ravi Chawla, MBA; Christine M. Colombo, MBA; Richard L. Snyder, MD; and Somesh Nigam, PhD
Value-Based Insurance Design and Medication Adherence: Opportunities and Challenges
Kevin A. Look, PharmD, PhD
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Rashid Kazerooni, PharmD, BCPS; Joseph B. Nguyen, PharmD, BCPS; Mark Bounthavong, PharmD, MPH; Michael H. Tran, PharmD, BCPS; and Nermeen Madkour, PharmD, CSP
Multiple Chronic Conditions in Type 2 Diabetes Mellitus: Prevalence and Consequences
Pei-Jung Lin, PhD; David M. Kent, MD, MSc; Aaron Winn, MPP; Joshua T. Cohen, PhD; and Peter J. Neumann, ScD
Prognostic Factors of Mortality Among Patients With Severe Hyperglycemia
Ya-Wun Guo, MD; Tzu-En Wu, MD, MS; and Harn-Shen Chen, MD, PhD
Survey Nonresponders Incurred Higher Medical Utilization and Lower Medication Adherence
Seppo T. Rinne, MD, PhD; Edwin S. Wong, PhD; Jaclyn M. Lemon, BS; Mark Perkins, PharmD; Christopher L. Bryson, MD; and Chuan-Fen Liu, PhD
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Cheng-Yi Lee, MS; Mei-Ju Chi, PhD; Shiang-Lin Yang, MS; Hsiu-Yun Lo, PhD; and Shou-Hsia Cheng, PhD

State of Emergency Preparedness for US Health Insurance Plans

Raina M. Merchant, MD, MSHP; Kristen Finne, BA; Barbara Lardy, MPH; German Veselovskiy, MPP; Casey Korba, MS; Gregg S. Margolis, NREMT-P, PhD; and Nicole Lurie, MD, MSPH
Health insurance plans serve a critical role in public health emergencies. The authors queried plans about issues related to emergency preparedness: infrastructure, adaptability, connectedness, and best practices.
Health insurance plans serve a critical role in public health emergencies, yet little has been published about their collective emergency preparedness practices and policies. We evaluated, on a national scale, the state of health insurance plans’ emergency preparedness and policies.

Study Design
A survey of health insurance plans.

We queried members of America’s Health Insurance Plans, the national trade association representing the health insurance industry, about issues related to emergency preparedness issues: infrastructure, adaptability, connectedness, and best practices.

Of 137 health insurance plans queried, 63% responded, representing 190.6 million members and 81% of US plan enrollment. All respondents had emergency plans for business continuity, and most (85%) had infrastructure for emergency teams. Some health plans also have established benchmarks for preparedness (eg, response time). Regarding adaptability, 85% had protocols to extend claim filing time and 71% could temporarily suspend prior medical authorization rules. Regarding connectedness, many plans shared their contingency plans with health officials, but often cited challenges in identifying regulatory agency contacts. Some health insurance plans had specific policies for assisting individuals dependent on durable medical equipment or home healthcare. Many plans (60%) expressed interest in sharing best practices.

Health insurance plans are prioritizing emergency preparedness. We identified 6 policy modifications that health insurance plans could undertake to potentially improve healthcare system preparedness: establishing metrics and benchmarks for emergency preparedness; identifying disaster-specific policy modifications, enhancing stakeholder connectedness, considering digital strategies to enhance communication, improving support and access for special-needs individuals, and developing regular forums for knowledge exchange about emergency preparedness.

Am J Manag Care. 2015;21(1):65-72
Health insurance plans are important stakeholders in the healthcare system and serve a unique role in public health emergencies. Prior systematic evaluations of how health insurance plans prepare and respond to these emergencies have not been reported, so we evaluated the preparedness of these key stakeholders. Responding plans represented 81% of health plan enrollment. We identified 6 modifications that plans could make to enhance healthcare system preparedness:
  • Establish metrics and benchmarks for emergency preparedness plans and policies.
  • Identify disaster-specific policy modifications.
  • Enhance state, local, and federal stakeholder connectedness.
  • Consider digital strategies to enhance communication.
  • Improve support and access for special-needs individuals.
  • Create regular forums for knowledge exchange about emergency preparedness.
Over the past 15 years, Americans have experienced multiple public health emergencies, including devastating natural disasters (eg, hurricanes, tornados, floods), environmental disasters (eg, the Gulf oil spill in 2010), bioterror incidents involving anthrax, the H1N1 pandemic, and mass casualty events that killed or injured scores of individuals.1-6 Additionally, as of August 2014, the World Health Organization declared the Ebola outbreak to be a public health emergency of international concern.7 The health and healthcare implications of these disasters have been quite varied. They have included the need to seek care in alternate locations due to destruction of communities or healthcare facilities, the loss of medicine or medical equipment, requirements for vaccines or other medical countermeasures, advanced trauma care, and care for the mental health sequelae of the disaster.4,5,8-14 While much has been reported about the preparedness and response of healthcare providers, far less has been published about those of health insurers.15,16 Public health emergencies can impact health insurance plans in multiple ways because of business disruptions, technology interruptions, or requests from patients and providers to deviate from normal coverage or payment policies so individuals can receive care and, subsequently, communities can recover.17

Health insurance plans clearly have an established responsibility in the direct financing of healthcare, yet less attention has been paid to the unique role that health insurance plans fulfill in public health emergencies.15,16 Notably, the ways in which health insurance plans structure policies for beneficiaries before, during, and after disasters can significantly impact how individuals access and use healthcare services during disruptive events and their aftermath. A surge in demand for medical care during disaster events, for example, can send communities in search of nontraditional healthcare providers or alternate care facilities.8,18,19 Maintaining continuity of operations and information about available resources is an important responsibility for health insurance plans. To achieve this, health insurance plans need to be able to rapidly inform beneficiaries of their level of coverage and, in some cases, relax benefit restrictions or create new emergency plans.17,20,21

The speed at which a health insurance plan can fulfill these critical responsibilities is, in part, contingent upon their disaster-management infrastructure and resources. Following Hurricane Katrina in 2005, America’s Health Insurance Plans (AHIP), the national trade association for the industry, convened its Readiness Task Force to identify strategies that health insurance plans use in disasters. A resulting white paper outlined the definition of a disaster, providing sample disaster plans and best-practice case studies of business models and policies.17 However, we are unaware of any systematic examination of how health insurance plans across the nation prepare for or respond to public health emergencies.21,22

As significant emergency events with broad impacts on health are currently in progress (eg, the Ebola epidemic)23,24 and will inevitably occur on a continuing basis, the study’s aim was to better understand the current state of preparedness of health insurance plans and to identify health insurance industry best practices for public health emergencies.


We surveyed health insurance plans across the United States to learn more about their preparedness and response policies and practices.

Study Population

We surveyed all health insurance plans that were members of AHIP, a national trade association whose members provide health and supplemental benefits through employer-sponsored coverage, the individual insurance market, and public programs (eg, Medicare and Medicaid) to more than 200 million Americans. We defined health insurance plans as companies providing a risk-based, primary care health insurance product based on a regional provider network.25

Survey Design

We developed survey content from a published report of the AHIP Readiness Task Force,17 federal guidance documents, 26-28 and input from emergency preparedness experts, representatives of health plans, and officials at various levels of government. The survey (eAppendix A, available at focused on 4 areas26-28: infrastructure (eg, existing emergency plans, metrics to evaluate these plans), adaptability (eg, events and triggers which might lead to an alteration of services, approaches to tracking and monitoring data, members with special needs), connectedness (eg, communication of plans to members and employees, ability to maintain up-to-date contact lists of partners, participation in collaborative exercises), and best practices/lessons learned.

We used information from the 2012 Directory of Health Plans, published by Atlantic Information Services, to determine each health insurance plan’s size, type of product, and area of operation. We categorized health insurance plans by size as follows: national (5 million or more enrollees), large (1 million to <5 million enrollees), medium (250,000 to <1 million enrollees), and small (<250,000 enrollees).

We pilot-tested the survey with 5 health insurance plans to ensure that the questions appropriately addressed the topic areas and were consistently understood by health insurance plan representatives. We also used the pilot to assess terminology, comprehensiveness, and response options. The primary recommendations from the pilot were minor edits and did not involve the addition or deletion of any questions developed for the survey.

Data Collection

AHIP notified the CEO of each plan about the voluntary survey. The survey was then sent to the person identified at each plan by AHIP as most responsible for business continuity or emergency preparedness (eg, chief medical officer, chief information officer, or chief operating officer). As needed, CEOs were contacted to facilitate survey completion. Follow-up calls were also made to promote engagement and address any questions that health plans may have had regarding the study. We distributed the survey via e-mail, with weekly reminders, from February 28 to May 1, 2013. AHIP also precontacted plans with incomplete or unanswered surveys by phone throughout the study period.


We calculated summary statistics and conducted bivariate analyses for key questions. To evaluate differences in responses by plan size, we used the χ2 test for differences among more than 2 proportions with (the application of) the finite population correction factor and Yates’ correction for continuity, as appropriate (ie, when >20% of cells had <5 count). All analyses were conducted using SAS 9.2 (Cary, North Carolina).


Of the 137 health plan members of AHIP, we received responses from 86 (63%). These 86 plans represent 81% of national private health plan enrollment and provide coverage for 190.6 million members across the United States. The responding plans varied by size, with the highest response rates from national (100%) and large plans (86%) compared with small plans (46%). We describe our major findings in Table 1.


All responding health plans had business continuity plans in place. Nearly all plans, regardless of size, reported having plans for business interruptions due to loss of critical infrastructure (eg, emergency power generators) or technical infrastructure (eg, information technology software or communication networks). Although there was variability by health plan size, most plans reported having emergency teams (85%) and emergency personnel (emergency recovery teams, 81%; disaster/emergency manager, 72%). Additionally, 59% reported having physical spaces (eg, emergency operations centers) for managing emergencies, and 40% reported having an emergency call center.

More than half of the health plans (59%) had established preparedness metrics to evaluate their emergency response and planning operations (eg, state of readiness [36%] or percent of operations restored [28%]), but we did not define these further in the study. There were no differences identified with regard to these metrics by health plan size.

Responding health insurance plans provided several concrete ways that they could further enhance their emergency preparedness efforts for both internal operations and member-related activities. These included use of social media outlets for communicating with members, customers, and providers; emergency preparedness webinars; construction of early alerts, checklists, lists of emergency contacts, and situational updates; and exercises for the industry to prevent and counter cyber attacks.


More than 95% of the plans indicated that a federal or state emergency declaration would trigger an internal review of their benefits (policy liberation). Most plans indicated that the changes they would most likely consider during an emergency period would include extending the time period for filing claims, revising or relaxating of out-of-network restrictions, and temporarily suspending business rules for prior medical authorization. Other changes they might consider include suspending business rules for precertification (61%), accepting incomplete claims due to record or data loss (51%), and ensuring the availability of electronic medical records to facilitate continuity of care (40%).

Some respondents reported having specific policies for assisting individuals with certain healthcare needs. Although more common in national plans, more than onethird of health insurance plans overall had capabilities to monitor and assist special populations: those dependent on durable medical equipment (34%), prescription drugs such as insulin or methadone (46%), and home healthcare (35%). Almost all the surveyed health insurance plans reported having the capability to use their claims data to monitor patient care needs, prescription medications, and provider/service utilization.


Although variability by plan size was identified, most health insurance plans indicated that they were able to communicate with stakeholders—such as members, employer groups, and providers—within 24 hours of a disaster. Prompt communication with public health officials occurred less often, and several plans indicated challenges in knowing who to contact within federal (61%), state (82%), and local (66%) regulatory agencies in the event of a disaster or public health emergency.

The vast majority (82%) of health insurance plans participated in internal preparedness drills. Fewer (30%) participated in preparedness drills with external stakeholders. Most expressed interest in engaging in these activities.

Lessons Learned and Best Practices

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