Liability and licensure hassles impede disaster response

Family physician Alvin Jackson, MD, was ready to drive his "hospital on wheels," from Fremont, Ohio, to Bay St. Louis, Miss., after he got a call last September to assist with Hurricane Katrina disaster relief.

With two exam rooms, a mini-pharmacy and a refrigeration system, his mobile facility was just what the staff at Coastal Family Health Center in Bay St. Louis needed to help the storm's victims. Dr. Jackson and his staff, some of whom were going to travel with him, normally use the unit to serve migrant workers, so they had the expertise in operating in the field that is valuable in disaster relief.

But Dr. Jackson, who works at Fremont's Community Health Services, was delayed a crucial five days as he worked to get the federal government to maintain his medical liability coverage across state lines.

A similar issue slowed down Wendy Ring, MD, MPH, a family doctor and medical director for Mobile Medical Office based in Eureka, Calif. It was a two-week struggle to make sure she'd have the medical licensure necessary to practice in Texas, where she was traveling last September to help with the large number of hurricane evacuees.

As Dr. Jackson, Dr. Ring and many other physicians like them prepare for the next disaster to strike -- whether it be a hurricane, a terrorist attack or the next flu pandemic -- they want to make sure these critical delays don't happen again.

The two physicians are among about 8,000 doctors who work for 1,000 federally qualified health centers across the country. They receive funding and compensation under the Public Health Service Act for providing primary medical care to low-income, underserved populations. About 80% of the clinics have government-provided liability insurance offered under the Federal Tort Claims Act.

"We are a perfect instrument for a health care delivery system to use in an area of devastation," Dr. Jackson said. "But the problem is, once we cross state lines, we no longer have the coverage necessary."

Dr. Jackson and his staff were able to go to Mississippi only after the Health Resources and Services Administration, which oversees federally funded community health centers, put them on a medical corps organized by the Health and Human Services Dept. Certified as federal public health service employees, they were allowed to maintain their federal coverage and granted the medical licensure necessary to practice in the state.

Dr. Ring, on the other hand, took a different route to get to the Fort Bend Family Health Center on the Texas-Louisiana border. The clinic helped her get a temporary Texas medical license, she explained, and adopted her as a temporary staff member so she could be covered under the clinic's medical liability insurance.

"This was another kind of delay that, if a national policy had been in place, could have been prevented rather than every state having to deal with it," said Dr. Ring.

Although the doctors found temporary solutions, they are concerned about what will happen the next time catastrophe strikes. When the Mississippi clinic requested Dr. Jackson's help again in January, he could not go because the government would not make the same arrangement to ensure he had liability coverage.

To fix the situation, the National Assn. of Community Health Centers is advocating for a bill that would amend the Public Health Service Act to allow community health center employees to maintain their federal liability coverage from state to state in emergencies. The measure, introduced last September and co-sponsored by Rep. Paul E. Gillmor (R, Ohio), would also protect out-of-state professionals from violating state medical licensure laws.

Meanwhile, delegates at the AMA Annual Meeting in June directed the Association to work with government agencies to find a way to honor doctors' medical licenses from state to state when they are providing care in an emergency. A report is expected at the AMA's Interim Meeting in November. To help doctors respond more immediately, the Association will also work to help create a uniform national picture ID that would help identify doctors when they enter a disaster area.

Related legislation introduced in the U.S. House last March with the support of the AMA would extend federal medical liability protections to doctors who volunteer at community health centers. Last September, the House passed the Katrina Volunteer Protection Act, with the support of the AMA, which would grant liability immunity to doctors who provided care to hurricane victims. The measure awaits Senate action.

The liability question was not raised immediately following 9/11, according to NACHC policy director Dan Hawkins. Hurricane Katrina, "for the first time, really involved clinicians crossing state lines to offer help, and it was at that point we learned that the interpretation [of the tort claims act] would prohibit the extension of coverage," he said. The protection should be construed broadly to shield doctors in these situations, Hawkins said.

Gillmor said the liability coverage offered under the tort claims act is meant to expand health care access by encouraging doctors to practice in health centers. But the unintended consequence is that physicians working at these facilities can't respond to out-of-state disasters because their liability coverage doesn't have that reach, he said. He anticipates a committee vote on his bill soon.

HHS and HRSA have not taken a position on the proposed legislative changes but agree that the size and scope of Katrina created a laundry list of lessons learned to improve preparedness and ensure patient safety.

"We will do everything we can within the statute to be of assistance in [disaster] instances," said Donald L. Weaver, MD, director of HRSA's Division of National Health Service Corps. He added that HRSA's main job is to ensure that the clinics are prepared in anticipation of emergencies that may affect their communities.

But Gillmor said that is shortsighted. "It's one thing where geography makes a difference, but here we have a health care professional trained in treating the injured or sick in a different area, and the risk and the conduct are the same," he said. "Just because they step across the state line, why should they lose protection?"

HHS spokesman Bill Hall said liability protections and state licensure are "just some of the issues we are trying to work through to have some seamless national system for health care providers to go across state lines and have those issues worked out ahead of time."