The National Disaster Medical System (NDMS) and the COVID-19 Pandemic

The novel coronavirus (COVID-19) pandemic has put a spotlight on systemic health capacity and coverage issues in the U.S.¹ As case counts continue to climb, the ability to test and treat all patients, including the uninsured, will continue to be a challenge. Similarly, there are questions about the out-of-pocket costs patients who are uninsured or under-insured may face. One possible mechanism for additional assistance, both in covering certain costs and in providing additional care and disaster planning is the National Disaster Medical System (NDMS). The NDMS is a network of intermittent federal employees made up of health and planning professionals trained to deploy in the event of a natural or manmade disaster, including mass casualty or loss of healthcare infrastructure, and during large public scale events. It also includes a program that can be used to reimburse health care providers for care provided to patients in a disaster. This explainer describes the NDMS, explores how it has been used in the past, and assesses how it is already being used or has been proposed to be used to fill gaps in the current response to the COVID-19 pandemic.

What is the National Disaster Medical System?

The NDMS is a coordinated network of 4,600 authorized intermittent federal employees organized into teams and trained to deploy in the event of a natural or manmade disaster, including mass casualty or loss of healthcare infrastructure, a disease outbreak, and during large public scale events.^2,3 NDMS teams offer “medical and emergency management services and subject matter expertise” at the request of federal departments, state, local, and tribal or territorial authorities.⁴ The NDMS is administered by the U.S. Department of Health and Human Services’ (HHS) Office of the Assistant Secretary for Preparedness and Response in partnership with the Department of Defense and Office of Veterans Affairs.

NDMS was first established in the 1980s to respond to military casualties but has since shifted to include a civilian focus.^5,6 NDMS operated administratively until it was authorized under the Public Health Security and Bioterrorism Preparedness and Response Act of 2002, which was created in response to the anthrax attacks to bolster national public health infrastructure.⁷ Its authority has been subsequently extended several times and it has shifted from being administered at HHS to within FEMA at the Department of Homeland Security, following 9/11, and then most recently, back to HHS after wide criticism of mismanagement of the Hurricane Katrina response.^8,9,10 It is currently authorized through the Public Health Services Act.¹¹ The HHS Secretary has broad authority to deploy NDMS without specific statutory triggers or thresholds needing to be met.¹²

NDMS personnel work in teams made up of physicians, nurses, dentists, logistical and safety specialists, and other health and support professionals¹³ and provide medical services, including public health support, medical transportation, veterinary services, and fatality management support, filling in the gaps of existing infrastructure.^14,15,16 For instance, NDMS teams may assist in health care settings, support medical shelters, provide prophylaxis during an outbreak, stand on-call during public events, or assist in wartime conflict. Teams can also deploy to assist in the “stabilization and transfer of all patients including ill/injured and nursing home patients.”¹⁷

Teams are typically activated for two weeks at a time and include:¹⁸

• Disaster Medical Assistance Teams (DMAT): Provide medical care and support during public health and medical emergencies in response to natural and manmade disasters, acts of terrorism, disease outbreaks, and special events. DMATs operate as self-sufficiently as possible with little resupply needed for the first 72 hours. DMATs include health care providers and non-clinical support staff and can deploy within eight hours of notification in 7, 14, or 35 person health and medical task force (HMTF) teams.
• Trauma and Critical Care Teams (TCCT): Provide trauma and critical care support during public health emergencies and special events, by providing a deployable advance unit, augmentation to existing medical facilities, patient transport preparation, or establishing stand-alone field hospitals. TCCTs include trauma and surgical professionals and deploy as 9, 10, 28, or 48-person units each with the capacity to conduct specific trauma related actions.
• Disaster Mortuary Operational Response Teams (DMORT): Provide services managing fatalities resulting from disasters, including victim identification support. Team structures include DMORT Fatality Management Assessment Teams and DMORT 12-Hour Morgue Operations Teams.
• Victim Information Center (VIC) Team: Supports local authorities during mass casualty events, including through the collection of ante-mortem data and liaising with victims’ families and other responsible parties in support of the DMORT.
• National Veterinary Response Team (NVRT): Provide veterinary care to service animals during disasters and large events. The NVRT is a single national team and includes veterinarians and animal health technicians.

Definitive Care Reimbursement Program

In addition to directly providing care to patients, the NDMS Definitive Care Reimbursement Program can reimburse eligible providers delivering definitive medical care to NDMS patients according to certain guidelines and provided funding is available.¹⁹ The NDMS definitive care reimbursement program is rarely activated and given statutory limitations on how the funds can be used, Congress has at times provided supplemental appropriations to bolster NDMS efforts, including for the 2005 Hurricane Katrina and 2010 Haiti earthquake responses (see below for details on the COVID-19 response).²⁰

Any Medicare and Medicaid participating provider giving care to an NDMS patient is eligible for reimbursement, including over 1,900 hospitals across the country that have signed an NDMS agreement and participate in the program.^21,22 Medicaid and Medicare providers that have not signed an agreement with the program can still receive reimbursement, albeit at a slightly lower rate. Facilities and practitioners are reimbursed at no less than the lesser of the billed amount or a rate closely tied to Medicare or Medicaid reimbursement levels (additional details provided in Table 1.).

Table 1: NDMS Definitive Care Reimbursement Rates

Reimbursement for Facilities (the lesser of):

1. Amount billed for covered services; or

2. 110% of Medicare Part A or Part B reimbursement (excluding pass-through payments), if facility has a MOA with NDMS; or

3. 100% of Medicare Part A or Part B reimbursement (excluding pass-through payments), if the facility does not have an executed MOA with NDMS; or

4. 100% of Medicaid reimbursement if the facility does not participate in the Medicare program or if the qualifying service is not covered under Medicare but is covered under Medicaid.

Reimbursement for Practitioner (the lesser of):

1. Amount billed for covered services; or

2. 100% of Medicare Part B reimbursement; or

3. 100% of Medicaid reimbursement if the practitioner does not participate in the Medicare program or if the qualifying service is not covered under Medicare Part B but is covered under Medicaid.

SOURCES: https://www.phe.gov/Preparedness/responders/ndms/definitive-care/Pages/reimbursement-rates.aspx, https://www.phe.gov/Preparedness/responders/ndms/definitive-care/Pages/participating.aspx,

How is the program funded?

NDMS administrative costs are funded through appropriations to the HHS Public Health and Social Services Emergency Fund under the Assistant Secretary for Preparedness and Response at HHS. In FY2020 the NDMS was funded at $57 million. The Trump Administration’s FY2021 Budget proposal, requested $88 million for the program, a $31 million (54%) increase over the FY2020 enacted amount. The increase in the FY2021 request is for the purposes of continuing a pediatric disaster pilot program ($20 million), maintaining 50 portable dialysis units ($5 million), supporting the emPOWER program ($1 million),²³ and training up to 6,7000 staff on field disaster medical operations, including highly infectious disease response ($5 million).²⁴

Deployment costs are not funded through the appropriations to the program and may be funded by the agency responsible for costs related to federal incident/event response. In other cases, HHS assumes the cost of deployment.²⁵ Additionally, NDMS administrative funding at the DOD and VA are not available.

Table 2: Federal NDMS Appropriations FY2017-FY2021 Budget Request
Fiscal Year	Funding Amount
FY 2017	$49,787,000
FY 2018	$57,404,000
FY 2019	$73,404,000
FY 2020	$57,404,000
FY 2021 Budget Request	$88,404,000
SOURCE: https://www.hhs.gov/sites/default/files/fy-2021-phssef-cj.pdf

When has it been used in the past?

NDMS has deployed teams to assist with more than 300 domestic and two international incidents since it was established with deployment of medical response teams in the wake of major disasters being the most common activation.^26,27

As noted, NDMS teams are deployed to provide medical support in response to disasters and emergencies such as floods, hurricanes, tornados, terrorist attack, or the wake of a disease outbreak, as well as large-scale national events such as Presidential Inaugurations, political conventions, and papal visits.²⁸

Examples of Past NDMS Deployments29,30

Hurricane Katrina Haiti earthquake in 2010 Sandy Hook Elementary School Shootings H1N1 influenza pandemic in 2009 Presidential State of the Union Address National Independence Day Celebration Rep. Elijah Cummings lying in state at the United States Capitol California Wildfires

Case Study: NDMS Response to 2017 Hurricanes31

In 2017, NDMS deployed to support to communities impacted by Hurricanes Harvey, Irma, and Maria in Texas, Florida, Puerto Rico, and the United States Virgin Islands (USVI). Over 4,800 personnel, including NDMS staff, joined the hurricane responses. The office of the Assistant Secretary for Preparedness Response deployed 944 tons of equipment and logistics and had over 36,000 patient encounters, including through NDMS along with other programs. In addition, specific to the Hurricane Irma relief effort, the Trump Administration activated NDMS’ Definitive Care Reimbursement Program to cover costs incurred by providers for definitive medical costs provided to about 85 medically evacuated patients from the US Virgin Islands being treated in Puerto Rico.

How is the NDMS being used to address the COVID-19 Pandemic?

The Families First Coronavirus Response Act, signed into law by President Trump on March 18, 2020, is the second major piece of legislation responding to the COVID-19 pandemic.³² The Bill includes $1 billion for the Public Health and Social Services Emergency Fund leveraging the National Disaster Medical System’s Definitive Care Reimbursement Program to deliver certain services.³³

The allocation in the Families First Act is specifically for the purposes of paying provider reimbursement claims for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19 and testing related visits for the uninsured. At this time the allocation does not appear to cover costs related to treatment for those with COVID-19, though the administration did reportedly consider this as a policy option at an earlier point.³⁴ Democratic presidential candidate Joe Biden has proposed expanding the authority and funding for the program to cover COVID-19 treatment costs for people who are uninsured as well as cost-sharing for people who are insured. The allocation for this limited purpose somewhat differs from traditional use of NDMS funding which can more broadly cover a range of health services related to the public health event.³⁵

In addition to providing reimbursement for certain COVID-19 related services, NDMS is positioned to assist with medical and strategic responses as requested, and has already been deployed to carry out several activities:

• NDMS teams have been reportedly deployed to strategic locations across the country, including to the states of Washington and Georgia, to provide support in caring for those who may have been exposed to SARS-CoV2.^36,37
• NDMS Disaster Mortuary Operational Response Teams (DMORTs) have also been deployed, including to support New York City Medical Examiner’s Office and provide portable facilities.³⁸
• In addition, a Disaster Medical Assistance Team (DMAT), along with other federal emergency workers, was deployed to support American citizens on the Diamond Princess cruise ship in Japan and at the U.S. Embassy to provide medical care, medication, and behavioral health support on February 12, 2020.³⁹
• Along with others, NDMS personnel staffed a National HHS Incident Management Team (IMT) to assist in the COVID-19 related repatriation efforts from Wuhan and Diamond Princess.⁴⁰
• Moving forward, NDMS could continue to deploy teams to COVIS-19 “hot spots,” bolstering regional health system capacity particularly taxed by the pandemic. For instance, NDMS could provide assistance to hard hit nursing homes to assist with care and transportation, as was done during Hurricane Katrina.⁴¹ Further, stipulations around any additional funding for provider reimbursement could be loosened to allow for coverage of treatment as well as diagnostics.