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.
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:
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.
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
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 www.ajmc.com) 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.
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 .
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
Many health plans shared specific lessons learned and best practices (). Identified themes include using preparedness planning software, conducting regular emergency preparedness exercises, creating and maintaining spare storage capacity before backing up data, and using text messaging to keep staff informed in the event of emergency. Notably, 60% of health plans expressed interest in participating in a forum to further share and communicate about their specific experiences related to emergency preparedness.
To our knowledge, these data represent the first national view of health insurance plans’ emergency preparedness. Responding health insurance plans represented more than 190 million members, accounting for 81% of total health insurance plan enrollment in the United States. While differences were observed across plans relative to size, many small and medium health insurance plans reported preparedness resources and infrastructure similar to large and national plans.
We identified numerous areas in which health insurance plans have made significant efforts to prepare and respond to emergencies affecting the health and healthcare of their employees and members. We also identified 6 ways that health insurance plans can modify or supplement their existing policies and practices to further the preparedness efforts of the collective healthcare system:
1. Establish metrics for evaluating emergency preparedness plans and policies, and use them for benchmarking. Most respondents had basic emergency preparedness tools and policies in place, and 59% reported using specific metrics for evaluating tools and policies. While metrics specifically listed in the survey were not exhaustive, less than half reported using readiness, percent of operations restored, or percent of critical systems tested for benchmarking. While intermittent surveys may provide a snapshot of health insurance plan preparedness, industry-developed metrics could be helpful for real-time and ongoing benchmarking of preparedness. Additional metrics could be adapted from the best practices of other businesses and tailored for the unique challenges that health insurance plans face.28
2. Identify policy modifications specific to health insurance plans for disasters. More than 80% of health insurance plans indicated they would make policy changes (eg, extending the time period for filing claims or relaxing out-of-network restrictions) in the event of a disaster, while some (40% to 50%) identified other modifications (eg, ensuring availability of electronic medical records to facilitate continuity of care or implementing a process to accept incomplete claims due to record or data loss). A need for specific service modifications has already been identified after prior disasters such as Hurricane Katrina,19 when patients with chronic illnesses were transported to offsite locations and needed access to medications. Similar challenges arose after the 2011 catastrophic tornado in Joplin, Missouri, when patients were displaced and needed assistance with medical record access29 and input from health insurance plans about relaxation of restrictions for out-of-network care.
3. Enhance health insurance plan connectedness with state, local, and federal stakeholders. While the network of organizations in a healthcare system is vast, it is possible to enhance emergency communications between health insurance plans and other healthcare organizations such as hospitals and health departments. Improvements could be made regarding the specification of contact individuals in various organizations, routine maintenance of contact lists and what information to share with public health officials, and participation in local and national drills. Health plans indicated that while coping with a disaster, they sometimes struggled with finding accurate, up-to-date information about available physical resources (eg, whether a particular hospital clinic or long-term care facility was open) and vaccines (eg, indications for use or availability). Related challenges—such as determining reimbursement policies for care in nontraditional environments or service areas with voluntary evacuations, rather than government-mandated evacuations—weren’t directly evaluated in this survey, but they have been identified by healthcare providers and healthcare organization leaders in informal post-emergency debriefings and meetings.
Improving healthcare system connectedness (eg, contact lists, drills) and information exchange is consistent with the National Health Security Strategy Implementation Plan (2012) and guidance from the Hospital Preparedness Program. Both promote healthcare coalitions (HCCs) as models for fostering engagement of organizations across various sectors.27,28,30 In this context, HCCs bring together healthcare stakeholders for leveraging resources, drills and exercises, engagement, integration across groups, enhancing situational awareness, and other activities. This coordination of healthcare organizations and resources has improved some aspects of response in many events, including the Boston Marathon bombing and Hurricane Sandy.4,9,31
4. Consider digital strategies to enhance communication. In the current information technology age, in which individuals and organizations are increasingly connected through networks and mobile phones, digital-based strategies for data collection and message dissemination could also help the emergency preparedness of healthcare systems and health insurance plans.32-35 Streamlined, readily available approaches for information surveillance and exchange (eg, websites, telephone hotlines, short message service text) could be very useful in this context.
5. Improve support and access to resources for individuals with special needs. Individuals reliant upon electricity-dependent medical equipment and life-sustaining healthcare services are particularly vulnerable in disasters that result in prolonged, widespread power outages since their access to care and other needed resources can be severely disrupted.36-39 Our survey revealed that most health plans have policies and the capability to use claims and other data systems to help monitor potential care interruptions, access to healthcare services and facilities, and reliance upon life-maintaining medical equipment. Broad adoption of such practices continues to improve health plans’ ability to anticipate community needs during a disaster and to promote emergency planning strategies for particularly vulnerable individuals.
6. Create regular forums for knowledge exchange about emergency preparedness. Many of the plans commented on lessons learned from specific events (eg, 9/11, Hurricane Sandy, the H1N1 outbreak), and indicated an interest in participating in forums to further share their experiences. Such venues could help insurers act on many of the study findings and advance the broader preparednessof health insurance plans and the healthcare system, including a focus on emergency plan development and the implementation of such plans across the health insurance community.
Because large plans were more likely than smaller ones to respond to the survey, we cannot readily assess the generalizability of findings across all health plans. However, because responding plans cover such a large percentage of the nation’s insured, the findings from our study do apply to most of the population. In addition, all data are based on self-reporting, so we cannot assess the degree to which the plans, policies, and capabilities could actually be used in an emergency. To date, standardized questions to assess the preparedness of health insurance plans have not been developed, so there may have been relevant content omitted from the survey that could be helpful for describing preparedness. This study represented a snapshot of health insurance plans’ preparedness, while future work could focus on tracking preparedness over time and evaluating the performance and improvement of emergency strategies in subsequent events.
Health insurance plans are important stakeholders in optimizing the nation’s emergency planning and response, particularly for catastrophic events that impact both a community’s health and healthcare systems, and have made significant efforts to prioritize emergency preparedness practices and policies. Additional sharing and spread of best practices, development and use of preparedness metrics for health plans, improved communication with external stakeholders, access to emergency resources, drills and exercises, and knowledge exchange across plans for lessons learned can further contribute to disaster preparedness and response.
We gratefully thank the health insurance plan professionals who participated in the survey.Author Affiliations: Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response (RMM, KF, GSM, NL), Washington, DC; America’s Health Insurance Plans (BL, GV, CK), Washington, DC; Perelman School of Medicine, University of Pennsylvania (RMM), Philadelphia, PA.
Source of Funding: None reported.
Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. The views expressed are solely those of the authors and do not necessarily represent those of the US Department of Health and Human Services.
Authorship Information: Concept and design (RMM, KF, BL, GV, CK, GSM, NL); acquisition of data (BL, GV, CK); analysis and interpretation of data (RMM, KF, BL, GV, CK, GSM, NL); drafting of the manuscript (RMM, KF, GV); critical revision of the manuscript for important intellectual content (RMM, KF, BL, GV, CK, GSM, NL); statistical analysis (GV); provision of study materials or patients (BL, GV, CK); obtaining funding (BL, GV, CK).
Address correspondence to: Raina M. Merchant, MD, MSHP, Health Policy Consultant, Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, 200 Independence Ave SW, Washington, DC 20201. E-mail: email@example.com; Raina.firstname.lastname@example.org.REFERENCES
1. Blanchard JC, Haywood Y, Stein BD, Tanielian TL, Stoto M, Lurie N. In their own words: lessons learned from those exposed to anthrax. Am J Public Health. 2005;95(3):489-495.
2. Quinn SC, Thomas T, Kumar S. The anthrax vaccine and research: reactions from postal workers and public health professionals. Biosecur Bioterror. 2008;6(4):321-333.
3. Redlener I, Reilly MJ. Lessons from Sandy—preparing health systems for future disasters. N Engl J Med. 2012;367(24):2269-2271.
4. Walls RM, Zinner MJ. The Boston Marathon response: why did it work so well? JAMA. 2013;309(23):2441-2442.
5. Osofsky HJ, Osofsky JD. Hurricane Katrina and the Gulf oil spill: lessons learned. Psychiatr Clin North Am. 2013;36(3):371-383.
6. Larson HJ, Heymann DL. Public health response to influenza A(H1N1) as an opportunity to build public trust. JAMA. 2010;303(3):271-272.
7. Statement on the 1st meeting of the IHR Emergency Committee on the 2014 Ebola outbreak in West Africa. World Health Organization website. http://who.int/mediacentre/news/statements/2014/ebola-20140808/en. Published August 8, 2014 . Accessed December 3, 2014.
8. Eastman AL, Rinnert KJ, Nemeth IR, Fowler RL, Minei JP. Alternate site surge capacity in times of public health disaster maintains trauma center and emergency department integrity: Hurricane Katrina. J Trauma. 2007;63(2):253-257.
9. Kellermann AL, Peleg K. Lessons from Boston. N Eng J Med. 2013;368(21):1956-1957.
10. Rambhia KJ, Watson M, Sell TK, Waldhorn R, Toner E. Mass vaccination for the 2009 H1N1 pandemic: approaches, challenges, and recommendations. Biosecur Bioterror. 2010;8(4):321-330.
11. Stroud C, Altevogt BM, Butler JC, Duchin JS. The Institute of Medicine’s Forum on Medical and Public Health Preparedness for Catastrophic Events: regional workshop series on the 2009 H1N1 influenza vaccination campaign. Disaster Med Public Health Prep. 2011;5(1):81-86.
12. Schreiber MD, Yin R, Omaish M, Broderick JE. Snapshot From Superstorm Sandy: American Red Cross mental health risk surveillance in lower New York State. Ann Emerg Med. 2014;64(1):59-65.
13. Gibbs L, Waters E, Bryant RA, et al. Beyond bushfires: community, resilience and recovery—a longitudinal mixed method study of the medium to long term impacts of bushfires on mental health and social connectedness. BMC Public Health. 2013;13:1036.
14. DeSalvo K, Lurie N, Finne K, et al. Using Medicare data to identify individuals who are electricity dependent to improve disaster preparedness and response. Am J Public Health. 2014;104(7);1160-1164.
15. Raymond AG. Resilience in disaster’s wake. AHIP Cover. 2008;49(1):16-24,26-27.
16. Kertesz L. Preparing for pandemic: health plans partner with federal agencies to address the threat of avian flu. AHIP Cover. 2006;47(1):12,65,67 passim.
17. Preparing the way—disaster readiness planning for health insurance plans. America’s Health Insurance Plans website. http://www.ahip.org/Issues/Documents/2007/Preparing-the-Way-%E2%80%93-Disaster-Readiness-Planning-for-Health-Insurance-Plans.aspx. Published 2007. Accessed December 3, 2014.
18. Stratton SJ, Tyler RD. Characteristics of medical surge capacity demand for sudden-impact disasters. Acad Emerg Med. 2006;13(11):1193-1197.
19. Darsey DA, Carlton FB Jr, Wilson J. The Mississippi Katrina experience: applying lessons learned to augment daily operations in disaster preparation and management. South Med J. 2013;106(1):109-112.
20. Bell A. Health insurers mobilize for Sandy. LifeHealthPro website. http://www.lifehealthpro.com/2012/10/31/health-insurers-mobilize-forsandy. Published October 31, 2012. Accessed December 3, 2014.
21. Missouri Department of Insurance offers guidance for Joplin tornado victims. Missouri Department of Insurance, Financial Institutions & Professional Registration website. http://difp.mo.gov/news/2011/Missouri_Department_of_Insurance_offers_guidance_for_Joplin_tornado_victims#.UjtC7H_9WRo. Published May 25, 2011. Accessed December 3, 2014.
22. Thompson DL. An integrated system for disaster preparedness and response. J Bus Contin Emerg Plan. 2011;5(2):118-127.
23. WHO Ebola Response Team. Ebola virus disease in West Africa—the first 9 months of the epidemic and forward projections. N Engl J Med. 2014;371(16):1481-1495.
24. Frieden TR, Damon I, Bell BP, Kenyon T, Nichol S. Ebola 2014—new challenges, new global response and responsibility. N Engl J Med. 2014;371(13):1177-1180.
25. AIS's Directory of Health Plans: 2013. Washington, DC. Atlantic Information Services website. aishealth.com. Accessed December 3, 2014
26. Office of the Assistant Secretary for Preparedness and Response. National Health Security Strategy. Public Health Emergency website. http://www.phe.gov/Preparedness/planning/authority/nhss/Pages/default.aspx. Updated May 22, 2014. Accessed December 3, 2014.
27. Office of the Assistant Secretary for Preparedness and Response, Hospital Preparedness Program. Healthcare preparedness capabilities: national guidance for healthcare system preparedness. Public Health Emergency website. http://www.phe.gov/preparedness/planning/hpp/reports/documents/capabilities.pdf. Published January 2012. Accessed December 3, 2014.
28. Guidance for businesses and employers to plan and respond to the 2009-2010 influenza season. CDC website. http://www.cdc.gov/h1n1flu/business/guidance/. Published February 22, 2010. Accessed December 3, 2014.
29. Shin P, Jacobs F. An HIT solution for clinical care and disaster planning: how one health center in Joplin, MO, survived a tornado and avoided a health information disaster. Online J Public Health Inform. 2012;4(1). pii:ojphi.v4i1.3818.
30. United States Department of Health and Human Services. Implementation plan for the National Health Security Strategy of the United States of America. HHS website. http://www.phe.gov/Preparedness/planning/authority/nhss/ip/Documents/nhss-ip.pdf. Published May 2012. Accessed December 3, 2014.
31. Powell T, Hanfling D, Gostin LO. Emergency preparedness and public health. the lessons of Hurricane Sandy. JAMA. 2012;308(24):2569-2570.
32. Merchant RM, Elmer S, Lurie N. Integrating social media into emergency-preparedness efforts. N Engl J Med. 2011;365(4):289-291.
33. Cassa CA, Chunara R, Mandl K, Brownstein JS. Twitter as a sentinel in emergency situations: lessons from the Boston Marathon explosions. PLoS Curr. 2013;5.
34. Keim ME, Noji E. Emergent use of social media: a new age of opportunity for disaster resilience. Am J Disaster Med. 2011;6(1):47-54.
35. Ng KH, Lean ML. The Fukushima nuclear crisis reemphasizes the need for improved risk communication and better use of social media. Health Phys. 2012;103(3):307-310.
36. Jenkins JL, McCarthy M, Kelen G, Sauer LM, Kirsch T. Changes needed in the care for sheltered persons: a multistate analysis from Hurricane Katrina. Am J Disaster Med. 2009;4(2):101-106.
37. Howard D, Zhang R, Huang Y, Kutner N. Hospitalization rates among dialysis patients during Hurricane Katrina. Prehosp Disaster Med. 2012;27(4):325-329.
38. Abir M, Jan S, Jubelt L, Merchant RM, Lurie N. The impact of a large-scale power outage on hemodialysis center operations. Prehosp Disaster Med. 2013;28(6):543-546.
39. Johnson DW, Hayes B, Gray NA, Hawley C, Hole J, Mantha M. Renal services disaster planning: lessons learnt from the 2011 Queensland floods and North Queensland cyclone experiences. Nephrology (Carlton). 2013;18(1):41-46.