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58–403 PDF 2011

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 

( 

(II) 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

JOSEPH I. LIEBERMAN, Connecticut, Chairman 

CARL LEVIN, Michigan 

DANIEL K. AKAKA, Hawaii 

THOMAS R. CARPER, Delaware 

MARK L. PRYOR, Arkansas 

MARY L. LANDRIEU, Louisiana 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

ROLAND W. BURRIS, Illinois 

EDWARD E. KAUFMAN, Delaware 

SUSAN M. COLLINS, Maine 

TOM COBURN, Oklahoma 

SCOTT P. BROWN, Massachusetts 

JOHN MCCAIN, Arizona 

GEORGE V. VOINOVICH, Ohio 

JOHN ENSIGN, Nevada 

LINDSEY GRAHAM, South Carolina 

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 

MARY L. LANDRIEU, Louisiana 

JON TESTER, Montana 

JOHN ENSIGN, Nevada 

GEORGE V. VOINOVICH, Ohio 

LINDSEY GRAHAM, South Carolina 

DONNY WILLIAM, Staff Director 

RYAN TULLY, Minority Staff Director 

KELSEY STROUD, Chief Clerk 

(III) 

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 

(1) 

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 

2 

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? 

3 

1The prepared statement of Mr. Fenton appears in the appendix on page 21. 

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. 

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 

4 

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. 

5 

1The prepared statement of Dr. Yeskey appears in the appendix on page 27. 

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. 

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 comVerDate Nov 24 2008 12:05 Apr 14, 2011 Jkt 58403 PO 00000 Frm 000009 Fmt 06633 Sfmt 06633 P:\DOCS\58403.TXT SAFFAIRS PsN: PAT
6 

munications 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 nonemergent 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 

7 

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? 

8 

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—— 

9 

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 DepartVerDate Nov 24 2008 12:05 Apr 14, 2011 Jkt 58403 PO 00000 Frm 000013 Fmt 06633 Sfmt 06633 P:\DOCS\58403.TXT SAFFAIRS PsN: PAT
10 

ment 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 

11 

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 followup 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 

12 

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 followup 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 

13 

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 everyVerDate Nov 24 2008 12:05 Apr 14, 2011 Jkt 58403 PO 00000 Frm 000017 Fmt 06633 Sfmt 06633 P:\DOCS\58403.TXT SAFFAIRS PsN: PAT
14 

1The prepared statement of Mr. Cunningham appears in the appendix on page 39. 

thing 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. 

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 

15 

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 

16 

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. 

17 

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—— 

18 

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 nonmedical 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. 

19 

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. 

20 

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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