Hurricanes, the Social Determinants of Health, Costs, and Compliance

The government of Puerto Rico’s official Hurricane Maria death toll at 2,975.

The 2017 hurricane season devastated entire regions of the globe, especially states and territories of the United States. Harvey, Irma, and Maria were a storm trifecta that yielded losses so profound, the communities in their paths will be reeling for decades. The combined impact of these storms exceeded the damage and deaths of Hurricane Katrina, with 2,975 deaths in Puerto Rico alone. Of the persons most severely affected, a majority were predisposed to the Social Determinants of Health (SDoH).

Estimates for financial costs of 2017’s storm trifecta are well over $300 billion. Each disaster now ranks in list of the top five costliest storms since 1980:

With the 2018 hurricane season just beginning, concerns exist for the people and communities continuing to rebuild their lives after prior storms. While a number of individuals have found a new norm, others continue to suffer. Many populations are predisposed to the SDoH, being already engaged in daily struggles with their employment status, social isolation, food insufficiency, access to health and behavioral healthcare, poverty, and public health concerns. In addition, hurricanes bring flooding, a major public health disaster, making the ramifications of any deluge another SDoH to reconcile. Physical losses of these storms appear in graphic detail across social media, with 24/7 broadcasts focusing on images of death, personal physical or property injury, and devastation.

Healthcare industry reports reveal how many lacked the necessary supports (human and/or financial) to move temporarily out of harm’s way to safer locations during the most devastating storms of 2017. Following Hurricane Katrina, a majority of those who remained in the 9^th Ward did so for lack of homeowners’ or flood insurance. In addition, disabled victims had additional challenges to overcome, with their move to shelters virtually impossible.

The Substance Abuse and Mental Health Services Administration’s (SAMSHA’s) July 2017 report provided a detailed yet comprehensive look at how people with both low incomes and socioeconomic status (SES) experience disasters. The data affirms the high cost of preparedness actions, which are often too costly for people in poverty to afford. A number of those most impacted by natural disasters lack the necessary insurance to protect their property (e.g. flood, earthquake, homeowners, etc.). During Katrina, districts of New Orleans with the highest percentages of people at or below the federal poverty level reported the lowest percentages of people with flood insurance. This fact further contributed to the unwillingness of many to leave behind cherished possessions. The high commitment of populations to protect their personal property often came at the expense of lives.

Educational Moments

Among the lessons learned from the storm trifecta include those tied to the dramatic impact to the healthcare system and its infrastructure in affected areas. To say there was a devastating ripple effect on payment and compliance is an understatement. At the height of the flooding for Harvey, every segment of the healthcare continuum was at issue. My conversations with colleagues in the region yielded stories marked by controlled chaos, at best. Hospitals faced grave shortages of food, medicine, and staffing. Those suffering from chronic diseases were forced to make life-and-death decisions between evacuation or sheltering in place. Dialysis and other specialty treatment programs were unable to care for all of those in need due to staffing and supply limitations. The high number of individuals who experienced prescription shortages were fodder for every news portal. Mental health emergencies were a common occurrence, particularly among those who experienced a rapid exacerbation of psychopathology due to lack of medication and/or counseling intervention.

The policy brief published by the Kaiser Family Foundation on this topic provides useful data and lessons learned across every practice setting, including:

• Public health
• Emergency/trauma care
• Primary care
• Medications
• Acute care
• Long-term care
• Mental health

The long-term recovery for regions is well-documented in the literature. Four in 10 affected residents who suffered the wrath of Harvey, Maria, and Irma have yet to receive the resources they need to recover. Many of those most impacted are minorities who had incomes lower than those of other members of the population, with their pre-storm access to resources limited at best. The most profound SDoH issues were already part of their reality. Unstable housing, inconsistent finances, limited or inappropriate food, and restricted access to necessary healthcare and mental health are still compromised by a societal structure still striving to right itself. The trauma endured by these populations further weakens their resilience, prompting chronic behavioral health situations.  

The Compliance Quandary

ICD10monitor published a two-part series following the 2017 storm trifecta that explored the need for practitioners to ensure compliance with non-clinical documentation of all social and environmental psychosocial stressors. This fosters management of the precarious reimbursement situations faced by institutions in these times by aligning the Z codes 55-65 with documentation to validate the SDoH. Particular non-clinical areas of consideration involve:

Problems related to other psychosocial circumstances:

• 5-Exposure to disaster, war, and other hostilities
• 4-Victim of crime and terrorism (if patients are victims of looting)

Employment:

• 0-Temporary unemployment
• 1-Change of job
• 2-Threat of job loss
• 82-Military deployment to assist

Problems related to housing and economic circumstances:

• 4-Lack of adequate food and safe drinking water
• 7-Insufficient social insurance and welfare support
• 9- Problem related to housing and economic circumstances

Other problems related to primary support group, including family circumstances

• 31-Absence of a family member due to military deployment (as military first responders)
• 4-Disappearance and death of family member
• 6-Dependent relative needing care at home (Z63.6), whether a chronic issue or temporary, as families are displaced.
• 7-Other stressful life events affecting family

The storm trifecta afforded the U.S. Department of Health and Human Services (HHS) several educational opportunities to guide its policies regarding its Privacy Rule during disasters. Exceptions to the HIPAA Privacy Rule are important considerations about which all organizations need to be aware.

While the majority of HIPAA requirements remain in effect during severe storms, the following exceptions are of note are the following:

• Should the President declare an emergency or disaster, andthe HHS Secretary declares a public health emergency, then the Secretary may waive sanctions and penalties against a covered hospital that do not comply with certain HIPAA provisions. These include:
• The requirements to obtain a patient’s agreement to speak with family members or friends involved in the patient’s care. 
• The requirement to honor a request to opt out of the facility directory.
• The requirement to distribute a notice of privacy practices.
• The patient’s right to request privacy restrictions.
• The patient’s right to request confidential communications.

This waiver only applies:

• In the emergency area and for the emergency period identified in the public health emergency declaration.
• To hospitals that have instituted a disaster protocol.
• For up to 72 hours from the time the hospital implements its disaster protocol.

As the HIPAA rules only apply to covered entities and their business associates, there are vital considerations for the resource and social services communities. The Red Cross, for example, is not subject to HIPAA and may use and disclose patient information in order to carry out its mission.

Moving Forward

The industry emphasis on the costs associated with the SDoH have only heighted urgency to address the topic as we enter hurricane seasons to come. The populations and communities predisposed to the SDoH are vulnerable to countless factors, particularly unexpected changes in the elements. Healthcare organizations must be proactive to ensure adherence to the programs and policies that fuel their financial sustainability.

Program Note:

Listen to Monitor Mondays on Sept. 10, 2018 for further discussion of the Social Determinants of Health and compliance concerns. In addition, register to join Ellen on Sept. 20 for the ICDUniversity “Removing the Stress from the ICD-10 Z ‘Stress’ Codes.”