Does the United States Need to Strengthen the System of Care for Infectious Diseases?

by Courtney A. Gidengil, Christopher Nelson, Laura J. Faherty, Nabeel Qureshi

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Research Questions

  1. What does experience with past outbreaks suggest about the strengths and gaps of the current system of care for rare but serious infectious diseases?
  2. How might the current system be strengthened or more formalized to address those gaps?
  3. How could a more formalized system be financed, both in terms of initial investments and long-term sustainability?

While the current system of care for treating rare but serious infectious diseases—which was developed in response to the 2014–2016 Ebola outbreak—provides an important foundation, a number of issues remain. In particular, a system of care must be able to sustain capacity and capabilities, manage the distribution of needed resources, and meet high demand for services. In this report, RAND researchers consider the need to strengthen the current system of care, discuss potential opportunities, and identify key financial considerations for the sustainability of the system.

This research suggests that the United States may benefit from a strengthened or more formalized system of care for rare but serious infectious diseases. The authors identify several opportunities to strengthen the current system of care, including enhancing or building upon the three tiers of acute care facilities that were established during the Ebola outbreak of 2014–2016, developing a brain trust of clinicians and others who can provide advice to health care providers, using mobile teams, and enhancing air and ground systems for safely transferring infected patients. The authors also lay the groundwork for future discussions around key financial considerations to ensure the sustainability of a system of care for rare but serious infectious diseases.

Key Findings

A more formalized system of care would be beneficial

  • There was strong consensus among working group members and other experts that a more formalized system of care for serious infectious diseases would be beneficial.
  • A more formalized and organized approach to care could integrate existing systems and resources, with the goals of harmonizing the response across federal agencies and reducing unnecessary variation in care.

The system should build on existing systems and resources

  • There was consensus within the working group that a strengthened system should neither start from scratch nor be superimposed on the existing approach to care.
  • Elements that could strengthen the existing system include enhancing the three-tiered system of facilities established during the Ebola outbreak of 2014–2016, developing a brain trust of clinicians and others to provide advice to health care providers, creating mobile teams, and enhancing air and ground systems for safely transferring infected patients.

Financial sustainability is critical

  • Existing incentives may not motivate health care facilities and systems to invest in increasing their capacity to respond to rare infectious threats when there is no clear or immediate return on investment.
  • Researchers identified and assessed a range of funding options that leverage existing assets and resources, create new funding streams, and create incentives that encourage hospitals to invest in providing care or that remove barriers to investment.
  • Federal funding sources may be important elements of a comprehensive strategy for financing a system of care.


  • Because many of the key assets and capabilities involved in caring for patients with rare but serious infectious diseases lie outside direct federal control, any effort to design and implement an improved system should engage a broad array of stakeholders.
  • The complex interactions among different organizations require a design process that features continuous experimentation and learning.
  • Given the difficulty in planning for highly infectious threats of uncertain origin, timing, and size, facilities could identify a range of plausible scenarios (based on past experience and expert opinion) and identify the likely amount of capacity and capability needed.
  • Regularly convening a mix of stakeholders in a standing working group meeting could help ensure that the various components of the system are designed to function effectively as a whole. An important charge for such a group would be to consider both financial sustainability challenges and such broader sustainability challenges as maintaining expertise, training, and operational readiness.
  • Regularly obtaining on-the-ground feedback on prototypes will be important. Prototypes might consist of verbal descriptions and diagrams of processes or tabletop exercises that ask participants to "play through" a proposed process using a written scenario. This approach would provide high-level, early input on system components to avoid further investment in ideas that are not feasible.

Table of Contents

  • Chapter One

    Background and Purpose

  • Chapter Two

    Analytic Approach

  • Chapter Three

    Examining the Current System of Care for Rare but Serious Infectious Diseases

  • Chapter Four

    Identifying Potential Approaches to Strengthening the Current System of Care

  • Chapter Five

    Exploring Financial Mechanisms to Sustain a System of Care for Infectious Diseases

  • Chapter Six

    Summary and Future Considerations

  • Appendix A

    Building on Other Systems of Care

Research conducted by

This research was funded by the Assistant Secretary for Preparedness and Response and carried out within the Access and Delivery Program in RAND Health Care.

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