As health officials all over the world continue efforts to prepare for and prevent the spread of the H1N1 virus, new strategies are emerging to help in the fight.

Last week, the Centers for Disease Control and Prevention's weekly update of the international situation surrounding H1N1 showed influenza activity increased in the United States, which was attributed to the start of the school year. Disease associated with H1N1 also increased in Africa, and the disease continues to circulate in tropical areas as well, the CDC reported.

There was some good news: the CDC report showed decreases in disease due to H1N1 in South America, parts of Australia, and the United Kingdom. In addition, there have been "no significant changes detected in the 2009 H1N1 influenza virus isolated from persons in the Southern Hemisphere as compared to viruses isolated from persons in the Northern Hemisphere," the CDC reports, indicating that the disease is not getting stronger.

These positive trends have not stopped healthcare leaders from taking innovative steps to control the virus—in some cases coordinating efforts with other providers in their individual countries and even others from all over the world.

The biggest effort, of course, is coordinating the development and distribution of a vaccine once it is available. The "U.S. government is working closely with manufacturers to take steps in the process to manufacture a 2009 H1N1 vaccine," according to the CDC. But as the Chicago Tribune reported today, it remains unknown whether enough vaccine can be produced and distributed quickly enough, or whether there will be delays due to unforeseen complications.

In the meantime, social media sites and other Internet-based systems are helping track the spread of the disease and report outbreaks. These sites offer people up-to-date information on H1N1 trends to keep people informed, and to help them take necessary precautions. Google Flu Trends, for example, provides estimates of flu activity in Australia, New Zealand, and the United States based on aggregated search queries. Flu Trends uses aggregated Google search data to estimate the current flu activity level in different countries around the world, "providing a multi-national, up-to-date flu tracking system," according to its Web site.

U.S.-based HealthMap also uses a variety of data sources to achieve a "unified and comprehensive view of the current global state of infectious diseases." HealthMap integrates outbreak data of varying reliability, including news sources personal accounts, and official alerts.

Officials are seeking to get consumers in on the act as well. Australia has launched FluTracking.net, a pilot health surveillance system to help detect influenza epidemics. Through FluTracking.net, people send emails updating symptoms which help Australia detect diseases to better protect citizens from the spread of disease.

Similar efforts have been developed in other countries, including Italy and Britain, as well as the U.S., including Maryland.

There are also ongoing efforts to prevent healthcare workers from getting H1N1 and spreading the disease to patients. An Institute of Medicine committee recently issued recommendations on protecting workers in healthcare settings against H1N1. The committee also advocates a boost in research to help design and develop better protective equipment to enhance workers' comfort, safety, and ability to do their jobs.

In addition, the Association for Professionals in Infection Control and Epidemiology has urged healthcare organizations to mandate that staff members in direct contact with patients are vaccinated during the upcoming flu season.

And in at least one region in the U.S., H1N1 preparations appear to be working: Hospitals downwind of Southern California's wildfires prepared for an onslaught of patients with respiratory problems as airborne debris exacerbated chronic conditions like heart and lung disease. But as my colleague Cheryl Clark noted in a recent article, these hospitals said they're ready for it because they are well stocked in anticipation of seasonal and H1N1 flu.

But these recent efforts to contain H1N1 have not instilled confidence in healthcare leaders, at least according to a HealthLeaders Media poll: 65% of respondents have said their healthcare facility is not adequately prepared for the potential outbreak of H1N1 this flu season.

Richard Tayrien, MD, will become HCA's Chief Health Information Officer, a new position, effective Sept. 21. Tayrien, 56, will lead an expanding team of clinicians and informaticists and be responsible for the continued development and implementation of hCare, HCA's program for advanced health information technologies. Currently, Tayrien is Vice President, Clinical Information Systems for Catholic Healthcare West, where he is responsible for strategy, development and implementation of clinical information systems. He previously was Regional Medical Director for Clinical Informatics at St. Joseph's Hospital and Medical Center/Barrow Neurological Institute. Tayrien practiced internal medicine for the first 18 years of his career.

In the most recent article in this series, we discussed federal healthcare contracting opportunities and issues of particular interest to small businesses. With the announcement in July of the Department of Defense (DoD) TRICARE contract awards, we turn to the opposite end of the spectrum and discuss issues affecting some of the largest healthcare contracts—not only in the federal marketplace, but in the entire domestic U.S. healthcare industry.

For over 20 years now, DoD has awarded contracts to manage the healthcare of non-active duty beneficiaries (e.g., dependents of active duty members; retirees, their spouses and children, etc.). Evolving from the Civilian Health and Medical Program for the Unformed Services (CHAMPUS), DoD moved to a managed care model in 1988 with the implementation of the CHAMPUS Reform Initiative (CRI). CRI converted the former CHAMPUS Program into a triple-option plan that added an enrollment option and a PPO option to a variation of the standard fee-for-service option that had been CHAMPUS. At the time, the government sought to create three geographical regions and place one contractor at risk for managing all of the care of military beneficiaries residing in each region. CRI eventually transitioned into TRICARE. TRICARE contracts were among the largest managed care contracts of any kind, and among the most highly sought after opportunities in the industry. The three regional contracts recently put up for bid were reportedly worth approximately $55 billion collectively.

The contracts have typically come up for competitive bid every five to seven years, but two of the three incumbents, Health Net and Humana, successfully defended their contracts for approximately 21 and 13 years, respectively. In what must be considered one of the most stunning upsets in recent federal contracting history, both Health Net and Humana were passed over in July for the most recent contract awards and were succeeded by Aetna and United Health Care.

Foundation Health, a predecessor to Health Net, was awarded the first contract under CRI in 1988 and Humana was awarded its first contract in 1996. Federal contracting rules call for most ongoing contracts to be competitively re-bid, generally every five years, and both Health Net and Humana have successfully defended their contracts in the past. Given the complexity of such contracts and the expertise contractors typically develop, incumbents in circumstances like this become increasingly difficult to dislodge. Over time, they develop unique past performance expertise that is critically important in subsequent competitions. The contracts become so complex that the risk of giving the business to the proverbial "new kid on the block" actually becomes a very significant factor in evaluating proposals.

Award of the TRICARE contracts is similar to the dynamics that emerge with other military procurement initiatives that are highly complex and possess unique requirements (e.g., sophisticated weapons programs, fighter jets, etc.), where the barriers to market entry are so significant that only the largest, most well-capitalized organizations can even consider submitting a proposal. Once awarded, the experience often helps reinforce the contractors' status as untouchable, and competitors are often discouraged from bidding, especially when the cost of proposal preparation and negotiation alone can easily reach of tens of millions of dollars. Collectively, these factors create an aura of unassailability, particularly when coupled with inevitable rumors of the contract being "wired." The combination of these factors often helps ensure that incumbents remain in place, as erstwhile competitors carefully consider the full implications of what it takes to dislodge incumbents of the status, expertise, and financial resources of a Health Net or Humana.

So the announcement last month that two of the three incumbent TRICARE contractors did not retain their contracts must be considered a highly unexpected development in military health circles. Since both contract awards have been formally protested, there is a possibility that the award decisions may be reversed. Until the jury is in, however, final judgment must be reserved, but there are several important lessons learned. The first is that no organization has a permanent "lock" on a federal contract, no matter how large, how complex, or how well-connected politically. Conventional wisdom about the power of incumbency, or rumors that the contract was wired from the start notwithstanding, the reality is that no one is always unassailable, and that while an extended track record by an incumbent contractor clearly works to its competitive advantage, it is not a guarantee in perpetuity.

While organizations are always well-advised to respect the power of the incumbency, the decision to walk away should not be based on the intimidation factor that goes along with an incumbent's track record, of, say, 10 or even 20 years. Test your assumptions; walk away if necessary . . . but walk away for the right reasons. This is a valuable lesson for hospitals or physicians that have long coveted a small, but prestigious contract with a local VA or military hospital. While a local provider who's held the contract for years may appear to have the business "locked-up", that assumption may be inaccurate. Time and time again, we see evidence where a longstanding, apparently entrenched contractor is unseated by another competitor that was not dissuaded by the challenge and put together a more attractive proposal.

Adding a fascinating element of intrigue to the TRICARE situation are reports that at least one of the reasons Health Net protested the award of its contract is because DoD posted some of Health Net's pricing information on a public website, an allegation which has actually been confirmed by DoD. Even if true, that does not guarantee a reversal of the decision. Requirements to uphold a protest of a federal contract are complex, and key among the issues likely to be considered include the timing of the release of the information and the extent to which the information can be shown to have had prejudicial impact. Since most of the details of the protests will remain proprietary until a decision is reached, it is really impossible for the general public to know what really took place at this point. Given the magnitude and significance of these contracts, we will continue to follow developments and offer commentary in subsequent articles as information emerges.