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Abstract

The definitive care component of the National Disaster Medical System (NDMS) may not be able to effectively manage tens of thousands of casualties resulting from a catastrophic disaster incident or overseas conflict. To address this potential national security threat, Congress authorized the US Secretary of Defense to conduct the NDMS Pilot Program to improve the interoperability, special capabilities, and patient capacity of the NDMS. The pilot's first phase was the Military–Civilian NDMS Interoperability Study, designed to identify broad themes to direct further NDMS research. Researchers conducted a series of facilitated discussions with 49 key NDMS federal and civilian (private sector) stakeholders to identify and assess weaknesses and opportunities for improving the NDMS. After qualitative analysis, 6 critical themes emerged: (1) coordination, collaboration, and communication between federal and private sector NDMS partners; (2) funding and incentives for improved surge capacity and preparedness for NDMS partners; (3) staffing capacity and competencies for government and private NDMS partners; (4) surge capacity, especially at private sector healthcare facilities; (5) training, education, and exercises and knowledge sharing between federal and private sector NDMS partners; and (6) metrics, benchmarks, and modeling for NDMS partners to track their NDMS-related capabilities and performance. These findings provide a roadmap for federal-level changes and additional operations research to strengthen the NDMS definitive care system, particularly in the areas of policy and legislation, operational coordination, and funding.

Introduction

The COVID-19 pandemic has demonstrated that the US healthcare system is ill-prepared for a large-scale or catastrophic medical surge event. Hospitals across the country have been overwhelmed with patients, and the US Centers for Disease Control and Prevention estimates that tens of thousands of excess deaths have occurred in the United States due to overcrowded intensive care units.¹

The US government defines a “catastrophic incident” to mean “any natural disaster, act of terrorism, or other man-made disaster that results in extraordinary levels of casualties or damage or disruption”² that is “of such extreme and remarkable severity or magnitude that the Nation's collective capability to manage all response requirements would be overwhelmed.”³ For more than a decade, there have been calls to better prepare the US healthcare system for catastrophic incidents that could cause tens of thousands of casualties, but there has been limited progress.^4-6

The National Disaster Medical System (NDMS) was established in 1984 to provide care for US military casualties and citizens following a military conflict, disaster, or other public health emergency.^6-8 The NDMS is a federal partnership led by the US Department of Health and Human Services (HHS), with the Departments of Defense (DOD), Veterans Affairs (VA), and Homeland Security (DHS).⁹ Its original primary purpose was “to provide medical evacuation and definitive care in the US for military casualties returning from an overseas war,” whereas its secondary mission was “to supplement state and local medical resources during disasters and emergencies.”^6-8 The NDMS has 3 main objectives: (1) provide medical assistance to support medical services in a disaster area, (2) evacuate patients that cannot be cared for in the affected area, and (3) provide definitive medical care to those affected by a conflict or natural disaster.^6-11 Currently, the definitive care component of the NDMS is composed of a national network of almost 1,900 DOD inpatient military treatment facilities, VA medical centers, and private-sector hospitals (with the last group representing nearly 90% of the total).^9,11

Without a large-scale conflict or catastrophic incident since the NDMS's inception, the NDMS patient movement and definitive care components have been rarely used and were not activated during the COVID-19 pandemic. One rare example of NDMS patient movement was when thousands of patients were evacuated from New Orleans, Louisiana, after Hurricane Katrina in 2005; in this instance, the NDMS was only able to evacuate and track less than half of 4,000 patients from the New Orleans airport.^4,6,12 By contrast, NDMS operations to date have focused almost exclusively on its medical assistance team component, which has been used to support state, local, tribal, and territorial authorities' responses to local disasters through the deployment of Disaster Medical Assistance Teams and other support services to supplement local medical response capabilities.⁶

Over the past 50 years, disasters in the United States typically have involved a small fraction of the potential 100,000 or more people who may be injured in a near-peer overseas conflict, urban nuclear attack, or major urban earthquake.¹³ Recognizing these potential scenarios and the limitations of the NDMS, Congress authorized DOD in December 2019 to conduct the NDMS Pilot Program in collaboration with the DHS, HHS, US Department of Transportation, and VA to improve the interoperability, capabilities, and capacities of the NDMS.¹⁴ The pilot is being implemented over 5 years through 5 regional NDMS networks composed of federal, state, and private-sector entities including federal coordinating centers (FCCs), hospitals, and HHS Healthcare Coalitions.^15,16 The pilot's first phase, the Military–Civilian NDMS Interoperability Study, started in fall 2020 and was designed to guide pilot implementation by providing insights into the current ability of the NDMS to provide medical care for large numbers of combat casualties.

Material and Methods

This study employed a qualitative approach using semistructured facilitated discussions designed to broadly identify critical challenges in existing NDMS operations and opportunities for improvement. Before each discussion, facilitators from the pilot research team presented a scenario describing activation of the NDMS to provide definitive care for 100,000 combat casualties returning to the United States over a period of months in response to a large-scale overseas military conflict. Facilitators used a formal guide to solicit broad, largely unconstrained feedback (eg, “What are your thoughts on our ability to distribute combat casualties across the NDMS definitive care hospitals?”) and specific questions about the strengths (eg, “What do you see as the current strengths of your area's medical surge capacity?”), potential obstacles to sustaining these strengths (eg, “What, if any, threats could impede those opportunities?”), weaknesses (eg, “What do you see as the current challenges facing medical surge capacity?”), and possible solutions to these weaknesses (eg, “What do you consider the potential solutions to each of the challenges?”). The discussions also addressed military–civilian interoperability (eg, “How would you describe military–civilian NDMS interoperability with respect to combat casualty management?”).

Between December 2020 and April 2021, the pilot research team conducted 18 facilitated discussions with purposefully selected federal and private sector NDMS stakeholders with expertise in clinical, operational, financial, and administrative aspects of the NDMS.¹⁷ Stakeholders included senior leaders and NDMS subject matter experts from the DHS Federal Emergency Management Agency, DOD, HHS Office of the Assistant Secretary for Preparedness and Response, US Department of Transportation, VA, emergency medical services, and private healthcare facilities.

The study included 49 total participants across the 18 total discussions. Four of the participants attended virtual discussions alone; the other 45 attended 1 of 14 small group virtual discussions, each with 2 to 11 participants. The group discussions were structured according to stakeholder affiliation (ie, federal government agencies or civilian/private sector healthcare entities).^17,18 Among the participants, 35 represented federal government agencies and 14 represented civilian/private sector healthcare entities. This approach ensured the collection of participant-engaged data and also served to build partnerships with participating stakeholders on emerging findings to inform improvement priorities for NDMS definitive care.^19-21 The facilitated discussions were voice recorded (with the prior consent of participants) to ensure data accuracy. Verbatim transcripts of each discussion were produced and edited for accuracy. The Human Research Protections Program Office for the Uniformed Services University of the Health Sciences reviewed the study protocol and determined it to be exempt research under federal regulations governing DOD-funded research.²²

Transcript data were qualitatively analyzed using NVivo version 12 Plus (QSR International, Burlington, MA) through an iterative inductive process. First, 3 pilot research team members individually reviewed all transcripts to extract and group key statements into common themes and subthemes identified through established qualitative analytic approaches (eg, sentiment analysis and text mining).^23,24 Next, the 3 team members met to discuss the coding results, reconcile differences, and consolidate or revise codes. Lastly, the most experienced researcher reread and recoded all of the transcripts using the reconciled coding schema.²⁵ This process resulted in 6 major themes that adequately represented the interview content.

Results

The 18 facilitated discussions resulted in 19 hours of recordings and 655 pages of transcripts. There was widespread agreement across all stakeholders that NDMS definitive care had fundamental weaknesses and opportunities for improvement. The 6 themes were: (1) coordination, collaboration, and communication; (2) funding; (3) staffing; (4) surge capacity; (5) training, education, and exercises; and (6) metrics, benchmarks, and modeling. The Table presents these themes, along with specific weaknesses and opportunities identified for improvement.

Table.

The Military–Civilian NDMS Interoperability Study Facilitated Discussion Themes, Subthemes, Weaknesses, and Opportunities

Themes	Weaknesses	Opportunities
1a. Coordination	Lack of integration between federal government and regional coordination entities Inconsistent relationships between FCCs and local emergency management Limited direct military–civilian coordination for medical surge No overall federal plan for a large-scale military medical surge scenario NDMS definitive care hospitals lack adequate plans for a long-term medical surge	Develop national entities to coordinate military and civilian partners Develop a single, standardized NDMS definitive care process and policy for all partners Develop a formal linkage between NDMS and the Strategic National Stockpile
1b. Collaboration	Local civilian partners (eg, emergency management, healthcare, public health) are not highly engaged with NDMS Civilian hospitals have limited understanding of their roles in the NDMS	Increase outreach and education for civilian NDMS healthcare facilities Develop a single, standardized NDMS definitive care process and policy for all partners
1c. Communications/IT	Existing IT systems do not provide accurate regional situational and bed capacity awareness Existing IT systems do not support the ability to equitably distribute patients	Develop IT infrastructure for accurate patient distribution and tracking Develop and implement a central IT system for military and civilian sector resource coordination Increase the use of telehealth
2. Funding	Civilian hospitals cannot afford to maintain continuous additional capacity Current NDMS reimbursement (110% of Medicare) is insufficient for long-term medical surge	Create federal incentives to maintain surge capacity in civilian NDMS hospitals Review existing payment schema for NDMS patient definitive care Fund regional healthcare command and control for daily and emergency use Create federal incentives to encourage civilian healthcare facilities to share capacity data
3. Staffing	Civilian healthcare facilities lack flexibility to move staff between states FCC staff often have multiple functions not related to NDMS FCC staff rotations, resignation, and retirement limit experience and historical knowledge ESF-8 desks are often staffed by public health, rather than healthcare, personnel	Ensure license portability for practitioners with laws and policies Establish malpractice insurance for providers at civilian healthcare facilities during an NDMS response Identify resources to support FCC staffing (eg, MRC, military reserve) Increase the use of the US Public Health Service
4a. Surge capacity (clinical)	Civilian healthcare partners are concerned about NDMS patient case management Procedures to balance patient load between healthcare facilities do not exist Limited specialty care capacity (eg, burn, trauma, CBRNE) Staff limitations are more critical than space limitation for a catastrophic incident	Assess the surge capacity of military and civilian NDMS healthcare facilities Include ambulatory, specialty, and long-term care sites as NDMS definitive care partners Identify resources for the unique needs of military patients in civilian healthcare facilities
4b. Surge capacity (patient movement)	The US military does not have sufficient domestic or global capacity to move large numbers of NDMS patients Limited planning to move specialty patients (eg, CBRNE) Limited capacity to transport patients from landing sites (ie, PRAs) to hospitals	Assess patient transportation capabilities from arrival in the US to definitive care hospitals
5. Training, education, and exercises	Military and civilian healthcare systems rarely share expertise to improve coordination and planning Civilian healthcare facilities are not incorporated into large-scale military exercises Limited NDMS-specific education and training Most exercises rely on untested assumptions about NDMS capacities and capabilities	Conduct annual joint military–civilian planning, training, and exercises Regularly rotate military clinical providers through civilian healthcare facilities to train, build relationships Develop NDMS just-in-time training and materials Develop EMS training/education specific to the NDMS Establish a standardized FCC training package
6. Metrics, benchmarks, and modeling	Preparedness metrics for the NDMS are not standardized	Develop a set of core NDMS definitive care partner metrics Benchmark FCC staging capacities and capabilities Develop NDMS-specific applied modeling to inform joint planning and response

Abbreviations: CBRNE, chemical, biological, radiological, nuclear, and explosives; EMS, emergency medical services; ESF, emergency support function; FCC, Federal Coordinating Center; IT, information technology; MRC, Medical Reserve Corps; NDMS, National Disaster Medical System; PRA, patient reception area.

Coordination, Collaboration, and Communication

Stakeholders identified several overarching weaknesses related to coordination, collaboration, and communication. Of particular concern was the federal government's lack of sufficient authorities, policies, and procedures to adequately manage the NDMS, and its limited interagency integration and fragmented authorities related to the NDMS. One DOD stakeholder remarked that “some of the authorities are […] problematic when it comes to activation and trying to determine who's responsible for what. […] there needs to be a centralized [federal] integrating factor.” A military stakeholder also noted, “We do not have a robust and practiced enterprise, wherein a federal authority can seamlessly work outside of silos between […] VA hospitals, DOD hospitals, and civilian public hospitals.”

Stakeholders also identified weaknesses in federal and private sector collaboration, including the lack of an overall federal management plan to coordinate care across the federal, state, and private sectors and the lack of planning for discharge, return-to-duty, rehabilitation, and return to home-of-record for military NDMS patients. With regard to coordination with the DOD, a civilian healthcare stakeholder observed, “there [may be…] plans on shelves, but in terms of true interoperable capability, there's really not that much.”

As a result of these deficiencies in planning and coordination, many private sector healthcare stakeholders do not understand their roles as NDMS partners. One civilian stakeholder stated, “I think the vast majority of [private sector NDMS] hospitals have no idea what they really are agreeing to do and have no real plan for how they're going to do it.” Another added, “If you asked many hospital administrators […] there's a good chance that some of them don't even know they're an NDMS hospital.”

Stakeholders identified opportunities to improve NDMS, coordination, collaboration, and communication such as creating regional healthcare coordinating organizations for more efficient patient distribution across private sector healthcare facilities, and increasing outreach to private sector healthcare leaders. Stakeholders also emphasized the opportunity to improve planning between federal and private sector NDMS partners, and that such planning efforts should build upon best practices from the COVID-19 response.

Funding

Funding was repeatedly identified as a major weakness. Private sector stakeholders especially noted that no financial incentives existed for their healthcare facilities to prepare for rare disaster events or to participate in the NDMS. Specifically, hospitals do not have a sufficient profit margin to maintain extra staff and space for surge capacity, and the current reimbursement to care for NDMS patients would not be sufficient for a large or extended event. One hospital administrator stated that “the competitive nature of healthcare today is to be super-lean, super-efficient, [… this] drives things that are [exactly the] opposite of surge capacity.”

The high cost of providing complex care to combat casualties by civilian hospitals over a long period of time was also identified as an issue. Another stakeholder commented on the current federal policy to reimburse care for NDMS patients, stating that “the reimbursement rate at 110% Medicare isn't going to cut it.”

Based on these weaknesses, stakeholders suggested funding opportunities that would create incentives to enhance hospital preparedness and surge capacity, such as changing the HHS Hospital Preparedness Program's funding methods or directing federal funding to large hospitals to offset the cost of preparedness. They also noted the potential need to revamp federal NDMS reimbursement plans (including DOD's TRICARE) to address the unique aspects of a large-scale combat event.

Staffing

Clinical and emergency management staffing were repeatedly mentioned as a weakness. Stakeholders noted that federal and local government emergency management agencies have limited staff and that NDMS responsibilities are added responsibilities without commensurate additional staff or funding. Staff attrition was also identified as a problem, particularly at FCCs, where the frequent attrition of personnel diminishes historical knowledge and expertise. One DOD stakeholder observed: “there's a diminishing line of return in regards to historical knowledge on the part of those working with FCCs right now. There are many that […] will be retiring. [W]hat is the backup to all those that currently have all this extensive knowledge?”

Stakeholders also identified clinical staff limitations as a problem for private sector healthcare facilities, especially highly trained personnel such as critical care, burn, and trauma specialists. Furthermore, stakeholders indicated that these limitations are exacerbated by a lack of flexibility to move staff between facilities and states as necessary.

Opportunities for improving staffing included using federal resources such as the Medical Reserve Corps for either emergency management or clinical positions, increasing the number of HHS case management teams to help NDMS patients navigate the healthcare system, and working with nonprofit organizations to supplement federal patient reception site operations. One participant specifically mentioned the need to strengthen the federal Emergency System for Advance Registration of Volunteer Health Professionals²⁶ to assist states in precredentialing providers for emergency response. Improving licensing and credentialing legislation and processes at the state level was also recommended.

Surge Capacity

Private sector stakeholders identified several challenges limiting surge capacity at their facilities, including a lack of staffed beds and limited preparedness to manage patient surge during catastrophic incidents. Concerns were also raised that FCCs are not adequately prepared to distribute NDMS patients to appropriate hospitals equitably, and that the NDMS has inadequate specialty care facilities (eg, trauma, mental health, rehabilitation) to accommodate a diverse large-scale patient volume. As one DOD stakeholder stated, “there's not enough […] specialty care facilities out there across the nation to take care of a large number of people with a large number of different type of injuries.”

The opportunities identified to increase surge capacity rely on accurate assessments of the existing capacities and capabilities of federal and private sector healthcare facilities in the NDMS network, and of other (nonhospital) facilities such as outpatient clinics, rehabilitation, and long-term care providers that could be included in the NDMS network.

Training, Education, and Exercises

Stakeholders acknowledged many weaknesses resulting from the NDMS never being activated for a large-scale overseas conflict or catastrophic incident and from the gap created by a lack of combat medical surge scenarios in standard homeland security exercises and evaluations. One DOD stakeholder highlighted: “we've never really tested this, and by not having done that, we're not sure this could work in the configuration that it's set in right now.”

Stakeholders also pointed out that substantial artificialities within current NDMS exercises limit their utility, stating that exercise play lacks reality by omitting all the “glitches” that would occur in a real-life situation. One example given was that in exercise play, “[you] wave a magic wand and all of a sudden 15 aircrafts [have been moved] and 3 FCCs [have been] stood up.”

These weaknesses are further exacerbated by inadequate sharing of military NDMS-related expertise with civilian healthcare partners through joint planning and training efforts. In describing past failed efforts for improving military–civilian medical interoperability, one civilian healthcare stakeholder observed: “It seems like there's a chance to move in a direction, and then either on the military side [or] the civilian side there's a controversy that stops it from going forward. […] But I don't think we've done much to exercise that or to make it a thing that works all the time.” As a result, private sector NDMS partners poorly understand federal and especially DOD's NDMS requirements, capabilities, and practices.

Stakeholders identified opportunities such as conducting joint federal–private sector training, education, and exercises; rotating military clinical providers regularly through private sector NDMS hospitals to enhance training; developing NDMS-specific, just-in-time training for military, nonmilitary federal, and private sector hospital personnel; and developing NDMS training, education, and exercises for emergency medical service providers.

Metrics, Benchmarks, and Modeling

Based on weaknesses mentioned throughout the discussions, stakeholders identified the need to standardize the NDMS and measure capabilities and performance more consistently and accurately. They suggested opportunities to develop assessment tools, metrics, and benchmarks to improve NDMS definitive care at all levels. A civilian stakeholder identified the need for “a small but very important set of metrics to be able to assess hospitals, [by a] regional center, to assess the hospitals' capacity within their region. Just to figure out things like what's their supply chain.” And a DOD representative recommended creating “[b]enchmarks that we all agree on that can really be used during practical exercises to evaluate the efficacy of NDMS.”

Additionally, stakeholders recommended the need for regional and national predictive models, stating that “there [are] plenty of models out there related to surge, and what that could look like based upon different scenarios for different hazards, [that we must] start using […] for purposeful planning.” To maximize their usefulness for planning and real-time response coordination, these models should include specialty services (eg, trauma, intensive care, psychiatry) and specific details about available staff and supplies.

Discussion

This article focuses on the definitive care component of NDMS specific to providing comprehensive healthcare services to combat casualties or victims of catastrophic incidents. The purpose of the study was not to identify specific problems and solutions, but rather to describe the most important themes requiring more detailed research. A diverse spectrum of stakeholders identified critical weaknesses and opportunities to improve NDMS interoperability, capabilities, and capacities. They nearly unanimously agreed that the current NDMS hospital-based definitive care structure would be incapable of managing definitive healthcare for a catastrophic incident.

Six themes emerged from the analysis that identified broad problems and potential solutions to improve the NDMS at the local, state, regional, and national levels. The themes were derived from stakeholder-identified weaknesses and opportunities that ranged from general statements and policy gaps to specific information technology and staffing solutions. For interpretation purposes, the identified themes relating to federal policy and procedures can be further categorized into: (1) policy and legislation, (2) operational coordination, and (3) funding.

Policy and Legislation

Across multiple themes, stakeholders repeatedly identified the need for a review of the federal government's laws, policies, authorities, and roles in providing central integration for the NDMS. For example, the current federal statutory authority for the NDMS is 20 years old.²⁷ It designates HHS as the lead federal agency and requires a “coordinated effort” by HHS, DOD, VA, and DHS working “in collaboration with the States and other appropriate public or private entities.” By contrast, current DOD policy maintains that while HHS is the NDMS federal lead during domestic emergencies, DOD acts as the lead during military health emergencies such as a military combat casualty scenario. In a military scenario, NDMS private sector partners serve as backups when both DOD and VA hospitals have reached capacity.¹¹ The statutory authority for this DOD policy is unclear, as it does not appear in the text of the currently codified NDMS statute.²⁷

A detailed review of existing policies at the federal, interagency, and state levels is needed to identify specific legislative and procedural changes to improve NDMS interoperability.

Operational Coordination

The definitive care component of the NDMS is a complex enterprise involving multiple government partners (ie, military and civilian at the federal, state, and local levels) and the private healthcare industry. Numerous participants commented on the difficulties of coordination and communication at each level, particularly for the private sector and local responders coordinating with the federal government and military. These issues arise from multiple identified problems (eg, dated federal policies and guidance), lack of training and education, and inadequate exercises. For example, the memorandum of agreement describing NDMS coordination between HHS, DOD, VA, and DHS has not been updated since 2005,²⁸ although the agreement template between the federal government and participating civilian healthcare facilities was updated in 2018.²⁹ State laws also impact coordination, particularly regarding professional licensure, and may limit the rapid shifting of staff to increase healthcare capacities in a specific region.

This study was consistent with previously reported findings that military and civilian partners are unfamiliar with the NDMS due to a lack of real-world activations, planning, education, and exercises between these partners.³⁰ Policy requirements for operational coordination across all NDMS stakeholder groups would likely result in more integrated planning, exercising, and resource sharing. These improvements would increase systemwide interoperability.

The coordination-related challenges identified by study participants echo prior recommendations for NDMS reform. In 2007, Franco et al⁶ made 3 suggestions for improving the NDMS's capacity to respond to future mass casualty disasters: (1) increase the level of engagement by the private sector healthcare system in preparedness and response efforts, (2) increase the reliance on regional hospital collaborative networks as part of the backbone of the NDMS, and (3) develop additional, alternative patient transportation systems to decrease the reliance on DOD air transportation. Similarly, Toner et al³¹ emphasized the critical need for integrated nationwide regionalized networks of hospitals, public health and emergency management agencies, and private businesses for a collaborative healthcare response. Regional groups should be interoperable and connected to enable horizontal cooperation within and across state borders. Patients should first be treated locally, then regionally, then in surrounding regions as the numbers demand.³¹ In 2008, the National Biodefense Science Board also recommended that a clear and current strategic vision for the NDMS be enunciated, and that “establishing improved alliances between NDMS and the public/private healthcare sector to provide assistance in field care, patient transport, and definitive patient care” is necessary to improve NDMS capacity.⁵

Federal efforts to improve healthcare preparedness exist, but they are not specific to NDMS preparedness for a high volume of military casualties. The HHS Hospital Preparedness Program³² provides funding to states, territories, and certain major metropolitan areas to coordinate the preparedness of hospitals and other healthcare facilities for disasters. The HHS Healthcare Coalitions established within this program have been proposed as healthcare response coordinating entities, but they generally do not have an operational component that organizes the healthcare response after a disaster.^33,34 The impact of the Hospital Preparedness Program has also been limited because its budget has been reduced by more than half in the last 2 decades, and it has been criticized for providing most funding to governments and not directly to healthcare facilities.^35,36

Since 2018, the HHS Office of the Assistant Secretary for Preparedness and Response has attempted to strengthen emergency healthcare response systems at the regional level with its Regional Disaster Health Response System demonstration projects in Atlanta, Georgia; Boston, Massachusetts; Denver, Colorado; and Omaha, Nebraska.³⁷ These project sites are intended to unify existing regional healthcare assets such as trauma systems, academic medical centers, and HHS Healthcare Coalitions to increase medical surge capacity, increase access to specialty clinical care, and establish best practices for healthcare response. These augmented regional systems remain in the demonstration phase, however, and must be thoughtfully scaled and sustained to support future national-level medical surge requirements.

Funding

Stakeholders, civilian hospital leaders in particular, raised concerns about narrow financial margins that limit healthcare facilities' preparedness activities and ability to maintain surge capacity. For decades, the US healthcare system has streamlined services and substantially reduced the number of inpatient beds in pursuit of efficiency. In 1980, there was 1 community hospital bed for every 222 US residents, but by 2018 there was only 1 bed for every 416 residents.³⁸ Under the current healthcare reimbursement model, no financial incentives exist to increase available surge capacity or preparedness activities for a rare catastrophic incident.

Stakeholders raised additional concerns that the current reimbursement for the care of an NDMS patient (110% of Medicare) would not be sufficient for a catastrophic incident or long-term NDMS event. For example, during the COVID-19 pandemic, hospitals saw massive financial losses as they were forced to shift care from highly reimbursed services, such as elective surgeries, to routine inpatient care of infected patients.³⁹ As a result, despite billions of dollars in relief funds from the 2020 Coronavirus Aid, Relief, and Economic Security Act (CARES Act)⁴⁰ to healthcare providers, a recent analysis estimated that the US healthcare system lost more than $54 billion in 2021 alone.⁴¹ In a catastrophic incident requiring a complete shift in healthcare delivery to meet the needs of military casualties or disaster victims, additional funding for healthcare providers will be needed for providers to remain financially viable. The country needs to explore direct and indirect incentives to increase its healthcare system's surge capacity and capabilities for rare but potentially devastating catastrophic incidents.

Study Limitations

The primary limitation of this study was the relatively small sample size and the potential for under- or over-representation of particular NDMS stakeholder groups. To mitigate the impacts of these sampling issues, the research team adopted a purposive sampling strategy and sought input from a broad array of stakeholders with expertise in various aspects of the NDMS (eg, clinical, operational, financial, administrative). The methods applied for the Military–Civilian NDMS Interoperability Study do not allow for generalization beyond the information presented in the findings, and the opportunities identified may not be actionable at all levels or across regions necessary for policy and practice decisions. However, the Military–Civilian NDMS Interoperability Study is the first phase of a multiphase program¹⁶ whose results will direct further research to identify specific interventions to improve NDMS definitive care at all levels.

Conclusions

The expert stakeholders in this study identified broad critical themes needed to improve the interoperability, capabilities, and capacities of NDMS definitive care, with a specific focus on the medical surge demands of a large-scale overseas military conflict. These themes are the foundation for further studies to be conducted by the NDMS pilot in 5 metropolitan regions across the United States, which will identify specific federal, state, and local interventions and policy changes needed to strengthen the NDMS definitive care system.

Acknowledgments

The authors thank Nicholas V. Cagliuso, Sr., PhD, MPH, for serving as a scientific advisor and contributing to the study design, data acquisition, data analysis, and data interpretation for this work. This research was funded by the Office of the Assistant Secretary of Defense for Health Affairs (Award No. HU00012020056) and administered by the Uniformed Services University of the Health Sciences. The information or content and conclusions reported in this work do not necessarily represent the official position or policy of, nor should any official endorsement be inferred on the part of: the Uniformed Services University of the Health Sciences, the US Department of Defense, the US government, or the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.

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Opportunities to Strengthen the National Disaster Medical System: The Military–Civilian NDMS Interoperability Study

Abstract

Introduction

Material and Methods

Results

Coordination, Collaboration, and Communication

Funding

Staffing

Surge Capacity

Training, Education, and Exercises

Metrics, Benchmarks, and Modeling

Discussion

Policy and Legislation

Operational Coordination

Funding

Study Limitations

Conclusions

Acknowledgments

References