[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]



 
               HOSPITAL DISASTER PREPRAREDNESS:
                  PAST, PRESENT, AND FUTURE 
_______________________________________________________________________

                           HEARING

                         BEFORE THE

                 SUBCOMMITTEE ON OVERSIGHT AND 
        
                        INVESTIGATIONS

                            OF THE 

                   COMMITTEE ON ENERGY AND 
                   
                          COMMERCE

                  HOUSE OF REPRESENTATIVES


                 ONE HUNDRED NINTH CONGRESS

                      SECOND SESSION
                      ______________

                     JANUARY 26, 2006
                      ______________ 

                    Serial No. 109-115

Printed for the use of the Committee on Energy and Commerce

 







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                      COMMITTEE ON ENERGY AND COMMERCE
                         Joe Barton, Texas, Chairman                  
Ralph M. Hall, Texas                         John D. Dingell, Michigan
Michael Bilirakis, Florida                    Ranking Member
  Vice Chairman                              Henry A. Waxman, California
Fred Upton, Michigan                         Edward J. Markey, Massachusetts
Cliff Stearns, Florida                       Rick Boucher, Virginia
Paul E. Gillmor, Ohio                        Edolphus Towns, New York
Nathan Deal, Georgia                         Frank Pallone, Jr., New Jersey
Ed Whitfield, Kentucky                       Sherrod Brown, Ohio
Charlie Norwood, Georgia                     Bart Gordon, Tennessee
Barbara Cubin, Wyoming                       Bobby L. Rush, Illinois
John Shimkus, Illinois                       Anna G. Eshoo, California
Heather Wilson, New Mexico                   Bart Stupak, Michigan
John B. Shadegg, Arizona                     Eliot L. Engel, New York
Charles W. "Chip" Pickering,  Mississippi    Albert R. Wynn, Maryland
  Vice Chairman                              Gene Green, Texas
Vito Fossella, New York                      Ted Strickland, Ohio
Steve Buyer, Indiana                         Diana DeGette, Colorado
George Radanovich, California                Lois Capps, California
Charles F. Bass, New Hampshire               Mike Doyle, Pennsylvania
Joseph R. Pitts, Pennsylvania                Tom Allen, Maine
Mary Bono, California                        Jim Davis, Florida
Greg Walden, Oregon                          Jan Schakowsky, Illinois
Lee Terry, Nebraska                          Hilda L. Solis, California
Mike Ferguson, New Jersey                    Charles A. Gonzalez, Texas
Mike Rogers, Michigan                        Jay Inslee, Washington
C.L. "Butch" Otter, Idaho                    Tammy Baldwin, Wisconsin
Sue Myrick, North Carolina                   Mike Ross, Arkansas
John Sullivan, Oklahoma
Tim Murphy, Pennsylvania
Michael C. Burgess, Texas
Marsha Blackburn, Tennessee
Gresham Barrett, South Carolina
                         Bud Albright, Staff Director
                        David Cavicke, General Counsel
          Reid P. F. Stuntz, Minority Staff Director and Chief Counsel
                                     _________

                            SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
                           Ed Whitfield, Kentucky, Chairman
Cliff Stearns, Florida                        Bart Stupak, Michigan
Charles W. "Chip" Pickering,  Mississippi       Ranking Member
Charles F. Bass, New Hampshire                Diana DeGette, Colorado
Greg Walden, Oregon                           Jan Schakowsky, Illinois
Mike Ferguson, New Jersey                     Jay Inslee, Washington
Michael C. Burgess, Texas                     Tammy Baldwin, Wisconsin
Marsha Blackburn, Tennessee                   Henry A. Waxman, California
Joe Barton, Texas                             John D. Dingell, Michigan
 (Ex Officio)                                   (Ex Officio)


             
                              
 
  
  











                            CONTENTS
 
                                                                   Page
Testimony of:
  Legarde, Mel, President and Chief Executive Officer, HCA 
   Delta Division, HCA, Inc...................................       34
  Montgomery, James T., President and Chief Executive Officer, 
   Tulane University Hospital & Clinic, HCA, Inc.............. 	     42
  Goux, Renee, Chief Executive Officer, Memorial Hospital, 
   Tenet Healthcare Corporation...............................       51
  Smith, Robert, Senior Vice President, Regional Operations-
   Texas/Gulf Coast, Tenet Healthcare Corporation.............       56
  Fontenot, Dr. Cathi, Medical Director, Medical Center of 
   Louisiana-New Orleans......................................       62
  Smithburg, Donald R., Executive Vice President-LSU System, 
   Chief Executive Officer, LSU Health Care Service Division..       67
  Sewell, Jon, Chief Executive Officer, Chalmette Medical 
   Center, Universal Health Services, Inc.....................       73
  Muller, Gary A., President and Chief Executive Officer, 
   West Jefferson Medical Center..............................       76
  Agwunobi, Dr. John O., Assistant Secretary of Health, U.S. 
   Department of Health and Human Services....................      122
  Guidry, Dr. Jimmy, Medical Director and State Health Officer, 
   Louisiana Department of Health and Hospitals...............      133
Additional material submitted for the record:
  Agwunobi, Dr. John O., Assistant Secretary of Health, 
   U.S. Department of Health and Human Services, response for 
   the record.................................................      155




















                    HOSPITAL DISASTER PREPAREDNESS:  
                       PAST, PRESENT, AND FUTURE
                            _______________

                            THURSDAY, JANUARY 26, 2006

                            House of Representatives,
                          Committee on Energy and Commerce,
                      Subcommittee on Oversight and Investigations,
                                                       New Orleans, LA.


The subcommittee met, pursuant to notice, at 10:00 a.m., in the Supreme 
Court of the State of Louisiana, 400 Royal Street, New Orleans, 
Louisiana, Hon. Ed Whitfield [chairman] presiding.
Present:  Representatives Burgess, Blackburn, Stupak, DeGette, 
Schakowsky, and Whitfield.
Also Present:  Representatives Melancon and Jindal.
Staff Present:  Kelli Andrews, Counsel; Mark Paoletta, Chief Counsel 
for Oversight and Investigations; Peter Spencer, Professional Staff 
Member, Kelli Andrews, Counsel; Jonathan Pettibon, Legislative Clerk; 
Edith Holleman, Minority Counsel; and Chris Knauer, Minority 
Investigator.
Mr. Whitfield.  Good morning.  I want to call this hearing to order 
this morning.  I want to welcome everyone in attendance today, and as 
the Chairman of the Subcommittee on Oversight and Investigations for 
the Energy and Commerce Committee, we are having this hearing today on 
Hospital Disaster Preparedness:  Past, Present, and Future.
Today at this hearing weï¿½re going to examine a number of different 
issues.  Of course, one that we want to focus on is quite evident 
from the title, is simply examining the hospital disaster 
preparedness prior to Katrina, and then, we hope to hear about lessons 
learned as a result of the unprecedented disaster brought by Katrina 
and Rita to this area.
I will tell you that yesterday, all of us on this subcommittee had 
the opportunity to visit for about five hours a number of hospitals 
in New Orleans proper, and we certainly visited many of the 
residential areas.  As one of those who had not had the opportunity to 
visit New Orleans since Hurricane Katrina, I would have to say that I 
was really overwhelmed by the devastation that we saw, and I donï¿½t 
really think people out in the Nation or around the world who simply 
hear the news reports of what occurred here or see pictures of it, 
really have a true understanding of how devastating this storm was.
I would urge every Member of Congress, as a matter of fact, or every 
Member of the U.S. Senate to take time to come and look at New Orleans, 
because none of us really had any appreciation for how bad it was.
I want to thank certainly those people with the LSU Hospital System 
yesterday, HCA, and others that took us on tours of their hospitals, 
because that was also an eye-opening experience for all of us.
I certainly want to extend a warm thanks to those of you who generally 
assisted our efforts in having this hearing in this courtroom this 
morning, in particular, Chief Justice Calogero and Justice Kimball, 
who graciously arranged for the use of this attractive venue for the 
hearing today.
Yesterday, we heard a lot of different explanations and stories of what 
happened, and we know that some of the plans and preparations made prior 
to Katrina had to be changed because of the severity of Katrina, so it 
did not work exactly as planned and I donï¿½t think that is unexpected.
We heard a lot of discussion about the problems that were met during 
the evacuation, and how, once again, these professional healthcare 
providers had to be quite flexible and innovative in solving some 
problems that came up.  We heard a lot about the difficulty of 
communication and the impact that that had on effectively evacuating 
patients from the affected hospitals.
I think that we realized that there isnï¿½t--we are not here today, I 
might emphasize, we are not here to try to blame anybody for what 
went wrong, because I think more things went right than went wrong 
when you consider the impact of the hurricane, but we do hope to 
come up with some possible solutions to help not only hospitals in 
this area, but around the country, maybe to be better prepared in 
the future.
Hopefully, we can also explore what is the relationship between the 
Federal government, the State government, the local government, and 
healthcare providers as they try to implement their mission of taking 
care of patients who need help.
And we all have the tendency, I think, to look for someone to blame. 
We have heard a lot about the shortcomings at FEMA, and there were 
shortcomings at FEMA, but I hope that this hearing can be quite 
positive and really explore, to try to come up with some answers to 
help in the future instead of fingerpointing.
So we will have some pointed questions for our witnesses, and I will 
introduce each of the witnesses when we get to that period, but I just 
want to thank you again for giving us this opportunity to be here. 
We do intend to look intently at all of these issues because they are 
quite serious, and it is a real opportunity for us to be here.  We 
look forward to the testimony of each one of you, because you are the 
experts, and we hope to learn from that testimony.
At this time, I would recognize our Ranking Minority Member, Mr. Stupak 
of Michigan, for his opening statement. 
[The prepared statement of Ed Whitfield follows:]

Prepared Statement of the Hon. Ed Whitfield, Chairman, Subcommittee on 
Oversight and Investigations

Good morning and welcome to this New Orleans field hearing of the 
Committee on Energy and Commerce Subcommittee on Oversight and 
Investigations.  Weï¿½ve called this hearing to examine hospital 
disaster preparedness and look especially closely at the horrific 
experiences - and hard lessons - of New Orleansï¿½ most critical hospital 
facilities, which stood square in the disaster zone created by 
Hurricane Katrina, thus suffering some of the worst the storm and 
flooding had to deliver.   
At the outset, let me extend my warm thanks to those who generously 
assisted our efforts to organize this hearing.  In particular, Justice 
Catherine Kimball, who sits on the Louisiana State Supreme Court, 
graciously assisted in the use of this attractive and convenient venue 
to put on the hearing.  
Also, Brigadier General Hunt Downer and the Louisiana National Guard 
guided us on a very informative tour through some of New Orleansï¿½ hard 
hit areas yesterday.  Without his thoughtful guidance, we would not 
come to this hearing with as much appreciation for the damage that 
Katrina wreaked.  
Holding this hearing in New Orleans provides subcommittee members the 
important opportunity to see first hand some of the circumstances that 
face health providers during and following a disaster.  Yesterday, as 
part of this effort, we toured some of the region.  Given the 
devastation that I witnessed yesterday I can better understand the 
frustration and anxiety New Orleans residents feel about the future of 
their city. 
Viewing this devastation in person gives me a greater appreciation for 
the difficulties people here have been confronting.  After the initial 
reports of Katrinaï¿½s destruction, particularly with respect to the 
health care infrastructure, we sent staff to the area in October to 
get an on-the-ground assessment. The extent of areas still 
uninhabitable today is heart-breaking.  And it underscores how 
critically important functioning hospitals are during and after a 
disaster.  My hope is that this hearing will shed light on how 
hospitals-an essential resource in a time of disaster-can better 
prepare for a catastrophe. 
This hearing will provide members an opportunity to identify key 
lessons from this horrible Katrina experience so the Committee, 
through its jurisdiction over public health and emergency preparedness, 
can more ably work to ensure health provider systems here and around 
the nation improve disaster preparedness.  It will also provide us 
important information about current efforts of hospitals to rebound 
from Katrina to meet the anticipated needs of New Orleans and its 
environs, actions which also have far reaching lessons for policy 
makers.
Today weï¿½ll hear directly from some of the hardest hit hospitals, 
which remain shut down five months after the storm - the Tulane and 
HCA  hospital, Tenetï¿½s Memorial Hospital, Louisiana State Universityï¿½s  
Charity and University Hospitals and Universal Healthï¿½s Chalmette 
Medical Center.  Weï¿½ll also hear from West Jefferson Medical Center, a 
hospital that was spared the flooding and operated through the 
disasterï¿½s aftermath and is now one of the essential facilities 
handling New Orleans current medical needs.  
Weï¿½ll hear about the emergency preparedness plans, and assumptions 
behind those plans, which these facilities deployed as Katrina 
approached. We should take a frank look at what went wrong, what went 
right, and how they managed, for this experience holds important 
lessons for future preparedness planning.  
Perhaps the single most critical failure involved the emergency 
power generation at these hospitals, which in many cases simply 
flooded out, leaving the facilities dark and helpless for several 
days as they sought to evacuate patients.  Iï¿½m looking forward to 
discussing this issue and what measures can and will be taken to 
ensure such life-critical power supplies when preparing for future 
emergencies.  
Weï¿½ll hear about back-up communications and the problems of simply 
talking to one another.  I look forward to learning about the 
communication and coordination among hospitals in the region - what 
seemed to work and what didnï¿½t, and what should be done to improve 
this important aspect of disaster response.   
Another critical topic to discuss today concerns hospital 
evacuations.  During a disaster, the assumption should be made 
that hospitals will remain open.  Hospitals are an essential part 
of the before, the during and, perhaps most importantly, the 
"after" parts of a disaster-helping a community to treat the 
acutely ill patient population and those that have been seriously 
injured or sickened because of disaster.  The hospitals in the 
New Orleans region were forced to evacuate due to the prolonged 
flooding.  We will hear first-hand about their efforts to evacuate 
in harrowing circumstances and, I hope, learn how patients may be 
evacuated in a more coordinated fashion in the future.
And weï¿½ll hear about both the current and anticipated health-care 
situation in New Orleans and what plans are being made as the 
health-care system continues to work its way back from the 
devastating effects of the flooding.  It is my understanding that 
hospitals including East Jefferson, West Jefferson, Oschner, 
Trouro and Kenner are all open for business.  Charity is also 
operating a makeshift medical center in the Convention center 
and we will hear plans for opening more facilities today.  
That said, recent press reports indicate that, among the 
evacuees that havenï¿½t returned home to New Orleans, are many 
doctors, nurses and other health care professionals.  According 
to these reports, this specialist shortage is forcing New Orleans 
residents to endure long waits for treatment or to turn to 
makeshift clinics for help.
If media accounts are accurate, this provider shortage appears to 
be a real challenge to public health and to rebuilding New 
Orleans.  One account quoted a local official estimating the 
acute-care capacity in the four-parish area at 1,750 beds, down 
from 5,063 before the hurricane.
I am concerned by these reports and look forward to hearing how 
New Orleans hospitals are working to meet these problems. 
Further, I hope that physicians, nurses and support staff of 
hospitals that may have moved out the region due to Katrina will 
hear this and come back to New Orleans.  
In addition to the hospitals, weï¿½ll also hear from the U.S. 
Department of Health and Human Services and the Louisiana Department 
of Health and Hospitals.  Both government agencies play an important 
role preparing for and responding to the urgent needs of critical 
care and special needs patients in time of emergency.  Iï¿½m looking 
forward to the perspective these agencies can bring to our 
discussion today.    
We have a limited amount of time today and a large number of 
witnesses, so let me again welcome the witnesses.  Thank you all for 
taking the time to tell us your experiences and explain from your 
perspective what happened and what we can learn from this disaster.  
And let me also welcome our colleague, Congressman Bobby Jindal, who 
represents the Louisianaï¿½s nearby 1rst Congressional District, and 
who has an established expertise in the matters we will examine today. 
Mr. Jindal, I understand you will be introducing one of our witnesses 
this morning.   
With that, I will now turn to my good colleague, Mr. Stupak, the 
ranking member for his opening statement. 


Mr. Stupak.  Thank you, Mr. Chairman, and thank for agreeing to hold 
this hearing down here in New Orleans.
If I may, just a little bit of a housekeeping matter.  First of all, 
I asked that our good friend and colleague, Charles Melancon, be 
allowed to sit at the dais with us today.  He is a great advocate for 
this area and he was instrumental in getting us down here.  So, I 
would like to have him sit with us.
Mr. Whitfield.  We are glad to have him here and he has been an 
effective spokesman for New Orleans in the U.S. Congress, and we 
welcome him here on the podium with us today.  
Mr. Stupak.  Mr. Chairman, I ask that my opening statement and the 
opening statement of all members be allowed to be presented for the 
record.  We have spent a few days putting together our thoughts.  I 
know I had a statement ready, but after being here and seeing 
firsthand what happened, that statement has changed.
It hasnï¿½t changed my commitment to work on this issue.  As you know, I 
have been bothering you for some time to bring the hearing here.  We 
did have a hearing in Washington, but we--Members on both sides--
wanted to have the hearing down here, so I appreciate you having this 
hearing.
I appreciate the fact that members like Ms. DeGette and Mrs. Blackburn 
really had to juggle their schedules to get here.  Members are really 
interested in what is going on and wanted to see what is going on here 
in the nature of healthcare, and really had to juggle their schedules 
to be here on somewhat short notice.  Our staffs worked long and hard 
to prepare us for this hearing.  I want to thank them.
As I said, we had a hearing in October in Washington, D.C. and we 
heard a lot of comments.  If they say a picture is worth a thousand 
words, being on the ground and actually seeing New Orleans and what 
happened to this gulf region is worth 10,000 years.  Or 10,000 words, 
I should say.  Hopefully it wonï¿½t take us 10,000 years to get it done, 
but at the rate it is going, it might be.
Sitting in Washington, and having an interest in healthcare and sitting 
on this committee for ten years, it can be a little frustrating when 
the Federal government moves slowly.  When it comes to healthcare, if 
Iï¿½m frustrated, I can imagine how our witnesses must feel and the 
people of New Orleans.
We have spent, or at least appropriated, close to $72 billion for the 
recovery effort, and after seeing things yesterday, the temporary 
levees, temporary healthcare, partial healthcare, and healthcare being 
delivered out of tents, you have to ask, where has this money gone?  
How is it being spent, how much is being spent for healthcare?
In the area of healthcare it looks like we are still waiting for 
decisions.  More importantly, at least for Charity, in healthcare, 
they are still waiting for more money.  They are over at the 
Convention Center in their tent hospital, if you will, and you have to 
applaud the medical professionals and administrators in this area for 
the work they are doing to deliver some semblance of healthcare, but I 
was struck by the fact that we have no Level 1 trauma center in a major 
city like New Orleans, no Level 1 trauma center in this gulf region 
without going a number of hours to find one.  But I was struck most by 
the fact that at your tent hospital, if you will, which has been 
running, I think, since early October and will be shut down by March 
seven or eight, right after Mardi Gras, not one penny, not one penny 
has gone to Charity to help them provide the services that are being 
provided.
Now, with $72 billion on the table, I would think the Federal 
government, FEMA, HHS, whoever is responsible, could at least spare a 
few pennies for the healthcare delivery being provided at the 
Convention Center.  Charity has had to lay off 90 percent of their 
people to try to make ends meet to pay the salaries of those who are 
still working and for supplies.  This is five months and they still 
canï¿½t get reimbursed?  I am struck by that fact.
And who, really, if you take a look at the history of healthcare 
delivery in this area, who are Charityï¿½s patients?  If I am correct, 
about 80 percent of the working poor make just enough money to stay 
off Medicaid.  They are Medicaid patients and they are the 
uninsured.  Where do these people go for healthcare if Charity is 
not there?  Charityï¿½s tent hospital, to my understanding, sees about 
3,000 patients right now a month.  What happens on March 7, when 
they close that tent hospital?
I mean, again, if I am frustrated, Iï¿½m sure other people must really 
be frustrated.
You know, if you take a look at it, I was also struck by the fact 
that we started our tour yesterday at University Hospital, and we 
did a couple more and we came back across the street and we went to 
Tulane Hospital.  Thatï¿½s part of the HCA healthcare system.  They 
seem to have the resources to redo their first floor and be putting 
in an emergency room, and they have done a great job.
Now, is that the private sector helping out one of their hospitals?  
And if the private sector can get it right and make a decision, why 
canï¿½t the Government get it right and help Charity and the other 
hospitals get back up and running?  Why did this one hospital--it 
struck me as we left the old Charity, walked across the street to 
the new hospital being done--Kim gave us that tour--and we just 
walked across the street and there you had lights.  The other side 
of the street didnï¿½t even have a light on.  It didnï¿½t make any 
sense.  Obviously, they are doing that right, so is that a business 
plan FEMA and HHS and Congress should look at, how do we get a 
hospital back up and running immediately?
It was just so many things struck me.  After seeing the damage 
firsthand, these questions have only become more frustrating, if you 
will.  The lack of answers.  Or maybe the questions should be more 
intense?  Iï¿½m not sure.  I mean, if we--as a country, we all realize 
the need for healthcare.  We can do it.  I question at times the 
willingness to do it.  Today, later on, Iï¿½m going over to 
Mississippi.  I want to see what is happening over there.  But 
every decision that the Federal government will make, Mr. Chairman, 
every decision we make is going to have a dramatic impact on the 
character of New Orleans and what it will be in the future.  We 
have to get these decisions right.  Every decision we make, every 
policy decision will affect who will be able to return and who 
will not be able to return.  Every policy decision we make, if it 
is private resources or public resources, will determine who will 
be allowed to come back to New Orleans and rebuild.
So, every decision that will be made will greatly affect the 
future of this great city.  I look forward to working with the 
Members of this delegation and with this committee and the U.S. 
Congress to make sure we rebuild this city and this region like 
it was before.  I think most of us have been here when New 
Orleans was running, vibrant, a great time.  Letï¿½s put that city 
back on the map and give it the healthcare it deserves and it 
needs.
Thank you, Mr. Chairman. 
[The prepared statement of Bart Stupak follows:]

Prepared Statement of the Hon. Bart Stupak, a Representative in 
Congress from the State of Michigan

Mr. Chairman, let me begin by thanking both you and the rest of 
my colleagues who have convened here today to see for ourselves 
the challenges of health care in New Orleans post-Katrina and meet 
on this very important subject of hospital and disaster preparedness. 
You have all traveled a great distance, and several of you canceled 
other obligations to be here.  Again, I appreciate the cooperation 
each of you have given and your professionalism in this endeavor.
The many crises suffered by the residents of Louisiana and 
Mississippi resulting from Hurricane Katrina and the breaking of the 
levees have been well-documented by the media, and the heroic medical 
personnel during and after the storm.  I have specific questions to 
ask about existing emergency communications systems and the 
credentialing of medical volunteers which I intend to explore later in 
my questions.  But for now, we must look forward at what has been lost 
and what should be replaced to prepare this city and its hospitals for 
the next disaster.
  	Mr. Chairman, Louisiana State University, Tulane University 
  	and the Charity Hospitals train the vast majority of medical 
  	personnel for this state.   They--and some of the other 
  	hospitals testifying today--train the doctors, the nurses, the 
  	dentists, the public health specialists and the technicians.  
  	They also are one of the major economic engines of 
  	New Orleans 
  	and the surrounding region.  This training system is in 
  	shambles because of Hurricane Katrina.   These institutions 
  	also provided the only Level I trauma care for the region and 
  	much of the general health care for the working poor and 
  	indigent.   
Just a few days ago, a story ran in the New York Times, which I would 
ask that we place into the record.  It describes the current condition 
of the New Orleans regionï¿½s hospital system.  In short, the article 
depicts a system that is overstretched, overwhelmed, and overworked. 
The article provides one small, but illustrative, example that is 
likely playing itself over and over again in the streets across this 
community.  Let me quote from it:

 Early one recent morning, doctors and nurses at East Jefferson 
 General Hospital in Metairie, just outside of New Orleans, were 
 already caring for five seriously ill patients in the emergency room - 
 because the hospital had no more beds to admit them to - while still 
 managing a full load of incoming emergency patients near the entrance. 
 Then two trauma victims from a car accident were brought in, followed 
 by someone showing signs of appendicitis.  The staff had to ï¿½play 
 musical chairsï¿½ with the accident victims and remaining patients to 
 find everyone a bed and care for them, said Cheryl Carter, the nurse 
 who directs emergency care.  "Thatï¿½s pretty much every day, pretty 
 much every hospital," Ms. Carter said.  "The waiting room looks like 
 a war center or a MASH unit.  We look for more and more different 
 ways to manage emergencies.

The article later describes another example, this time involving 
another major facility in New Orleans, Touro Hospital:

For patients [now living in New Orleans] a medical emergency usually 
means a long wait, unless it is life threatening.  Ben Cohen who is 28 
and lives in the Mid-city neighborhood started to have intense 
abdominal pain on January 15 and spent four hours in the Touro 
emergency room before he was admitted.  While there, he watched the 
single doctor on duty cope with a shooting victim and two trauma 
cases from a car accident.  "To their credit," Mr. Cohen said, 
"they did the best they could have."

Mr. Chairman, the Times article is replete with examples of how the 
system as a whole and how hospitals individually are still 
struggling to be prepared for the next major disaster; and one will 
surely come.  
Indeed, while many are--in the words of that patient--"doing the 
best they can," there are major questions that now confront this 
region from both a health care perspective and a preparedness point 
of view:  Is the city now ready for Mardi Gras?  Is this region now 
prepared for a major refinery explosion or barge accident with the 
multitude of trauma cases that could result?  Is this region ready 
for a major school bus crash on the now congested freeway?  What about 
the next hurricane season, which is now less than six months away?  
Finally, are they ready for day-to-day life as some families struggle 
to return or reclaim their lives?  
The Departments of Homeland Security and Health and Human Services 
have written voluminous and complex  preparedness plans for all kinds 
of catastrophes, but are they actually willing to provide the dollars 
that are required to implement them?  I do not believe that they are.  
I am not sure if it is good enough or reasonable to expect a medical 
system to continue this way indefinitely without some additional 
federal assistance.
Mr. Chairman, a number of us here have followed closely the plight 
of the health care system and hospital preparedness issues in this 
region following the hurricane.  As a number of major hospitals were 
either severely damaged or nearly destroyed by either wind or flood 
waters, many facilities are still struggling to either re-open, or 
are doing the best they can with what they have.  Most are just 
hoping things will improve.  Nevertheless, for many residents and 
for many outside observers, the pace of this effort remains slow 
and frankly, too uncertain.
 	Perhaps the most tragic hospital-related problem and now a 
 	major preparedness issue facing the New Orleans  region is 
 	the loss of the Medical Center of Louisiana which is 
 	comprised of two of the regionï¿½s largest hospitals: Big 
 	Charity and University Hospital.  Known together as 
 	"Charity," both were severely damaged by Katrinaï¿½s winds 
 	and the flood waters.  We visited both facilities yesterday 
 	and saw the resulting tragedy for ourselves.  What was once 
 	a major institution responsible for saving so many lives 
 	is itself on life support. 
Before the storm, these two hospitals provided the only Level I 
trauma care for Southern Louisiana and the Mississippi Gulf Coast 
region.  Presently, there is no Level I trauma facility for this 
region.  After the storm, there was a military unit at the Convention 
Center providing such care.  But it is no longer there because the 
military needed it elsewhere.  The closest facility now that provides 
level I care is hundreds of miles to the north in Shreveport or to 
the west in Houston.  It is my understanding that FEMA will be 
setting up such a facility for some duration, but the specifics on 
such a center are not yet known, and it is something that I hope 
this committee will explore further.
To understand what a loss these two hospitals are to the greater 
New Orleans area, and to understand how this loss directly impinges 
upon the level of preparedness for other hospitals, it helps to have 
some background on the demographics of the region.   
Before Katrina, almost 1 million residents in Louisiana lacked health 
insurance.  Many of these uninsured were comprised of the "working 
poor" who earned too much to be eligible for Medicaid.  They worked 
at jobs without health insurance benefits nor could they afford to 
pay co-pays or purchase private health insurance on their own.  In 
New Orleans alone, more than 20 percent of its residents lacked 
coverage.  Many more were dependent on Medicaid.  For Charity and 
University hospitals, 44 percent of its total admissions in fiscal 
year 2005 were comprised of patients with no insurance, while 
another 42 percent were covered by Medicaid.  Thus, more than 85 
percent of these two hospitalï¿½s patient base (or approximately 
275,000 of the regionï¿½s residents) were indigent or comprised of 
what is termed, "the working poor."  
Considering that the entire City of New Orleans was approximately 
500,000 before the storm, these statistics show what a complex 
patient mix was in place before Katrina.  It also suggests the 
impact the present and potentially-returning population will have 
on existing hospitals.  As many Louisiana residents have now lost 
their jobs, the increasing stress on this system is obvious.  
It is my prediction that these realities will continue to have a 
profound affect on hospital preparedness for the region.  Indeed, 
as we will hear today, some of the inner-city hospitals and some 
of the now functioning suburban hospitals are already struggling 
to meet the surrounding regionï¿½s medical and emergency needs. 
Hospital preparedness cannot take place in a vacuum.
There are certainly numerous questions regarding whether Charity 
or University hospitals can or should be rebuilt as before.  But 
there are also questions regarding whether other hospitals can 
accommodate the former patients of these hospitals if they cannot 
be rebuilt.   These profound questions must be addressed if New 
Orleans is going to successfully prepare for the next disaster 
and they should be front and center as part of this Committeeï¿½s 
inquiry.
 	Indeed, strategic planning to provide ongoing care for 
 	returning residents or even cleanup workers - particularly 
 	those with little or no insurance - appears insufficient.  
 	And while the small tent-based Charity operation currently 
 	set up in the convention center - which is seeing almost 
 	300 patients a day - is admirable, it cannot provide 
 	sufficient coverage for even a fraction of the existing or 
 	potential patients that may seek to return.  In short, the 
 	effort at the convention center--or the efforts at the 
 	other struggling hospitals that are doing the best they can 
 	with what they have--will likely be unable to provide 
 	sufficient care should a major disaster strike.  Let me quote 
 	from Mr. Smithburgï¿½s testimony who illustrates that point 
 	directly:

We know that improvements can and must be made in our capacity to 
handle hurricanes and other emergencies.  It is fair to focus on the 
emergency preparedness system, but at the moment we have too few 
hospitals standing to even participate in the next catastrophe.  The 
next bus crash or minor emergency will overwhelm current hospital 
capacity. . . . 

Mr. Chairman, as the old adage goes, "itï¿½s hard to go to church when 
your house is on fire."  In other words, it is hard to place 
generators above potential flood waters, or stock up on food for the 
next storm when the hospital may no longer exist and all its doctors 
and nurses have been laid off.   
How long the residents of this great city should expect to receive 
their health care services in overtaxed emergency rooms or even in 
the tents that we saw yesterday is something we should explore today. 
I for one would like to know answers to some of the following questions:

1.	What is the plan for bringing those major hospitals in this 
city that were destroyed by the storm back on line.   Does a formal 
plan exist? Are there clear milestones that lay out the steps that 
will need to occur for this to happen?  Is there existing funding.  
If not where will it come from? 

2.	What exactly is the process FEMA will follow?  Is the process 
transparent and fair? 

3.	What happens if certain key hospitals cannot be rebuilt 
because of a lack of funding?  Is there an interim plan to serve 
the patients they once served?  

4.	Is there enough space at existing facilities for current 
residents under normal circumstances?  What about in an emergency 
such as another major hurricane or that bus crash?   

5.	If, as some press accounts and testimony suggest--that some 
hospitals are already over-burdened--then what happens if another 
50,000 or 100,000 residents return to the city?  Is FEMA taking 
this into account as they review damaged hospitals or help pay for 
a temporary level I facility?   

6.	Is there a "scalable plan" to accommodate any new potential 
surge in demand?  This is a key question directly related to how 
and whether existing hospitals are prepared for the next major 
event.  As thousands of residents each month are receiving their 
medical care presently at a tent facility in the convention center, 
I question how additional hospitals could effectively take up this
slack in the future if they are having a difficult time doing so 
now.

Mr. Chairman, I again look forward to the testimony today and I 
again thank you for convening this important hearing.  I hope we 
can work together to find answers to some of these very difficult 
questions.  I am committed to working with you to that end.  Many 
people are really hurting down here.  The need for help only 
continues.  It cannot come too soon.  It is critical that we as a 
Congress and as national leaders play an aggressive role in 
finding answers and helping the people of this great region solve 
these daunting problems.
Mr. Whitfield.  Thank you.  At this time, I recognize the gentleman 
from Texas, who is the only physician here today.  Up here, at least. 
Mr. Burgess.  Thank you.  I do want to thank you for doing this.  
I do feel that this hearing is appropriately located in the city of 
New Orleans.  I do feel that this hearing is late, just as my 
colleague Mr. Stupak has mentioned.  I did visit the area myself in 
October.  Mr. Muller and the good folks of East and West Jefferson 
Hospital helped me to see and understand, feel, taste, and smell 
what they were dealing with.  And just like Mr. Stupak, I do have 
an opening statement for the record.
I would like to take a moment and just acknowledge what I saw in 
October and what I saw again yesterday and just the incredible 
sacrifice that has been made by the healthcare community here in 
Louisiana and around the Gulf Coast.  And I heard the stories a couple 
of months ago from your doctors, nurses, administrators, and 
biomechanical engineers, and heard the same stories again yesterday. 
It didnï¿½t matter what facility we were in, the people who stayed on 
the front lines, while their own families and homes were being savaged 
by storms and then its aftermath, I donï¿½t know if reaching deep down 
inside I would have had the courage to do what many of you have done, 
but you did it and you did it with class and I take my hat off to you.
I think I should also let you know, your colleagues up in my part of 
the world, in North Texas, Labor Day weekend, a call went out to 
Dallas County Medical Society, that we have got 70,000 people who 
have been displaced from the Superdome who were coming to the Union 
Arena in Dallas, Texas.  Out of 3,600 members of the healthcare and 
medical society, on a holiday weekend, 800 showed up to run the 
triage centers in the parking lot.
The medical community throughout this country can really be proud of 
itself and how it responded during the crisis.  But now it is the 
aftermath of this crisis that concerns me and how to protect and 
defend what remains of the medical safety net in New Orleans and the 
Gulf Coast and going forward.  How do we appropriately expense and 
replace that safety net as this unfolds?
I think, too, it struck me in October and it struck me again 
yesterday, the city itself is hardly prepared for just a regular 
flu epidemic, let alone something as devastating as a worldwide 
pandemic.
But we are learning.  I do want to hear--Iï¿½m particularly interested 
in the hospitalï¿½s emergency preparedness plans.  Mr. Chairman, I 
suggest that we may want to do another hearing at some point about 
how nursing homes have prepared themselves for what was coming with 
Katrina.  I suspect the level of preparedness was somewhat less than 
the hospitals, though I donï¿½t know that for a fact, but I do know in 
my part of the world, when Rita threatened, we lost more people 
because of the way we evacuated nursing homes than were actually lost 
in the storm itself.  So I think that is something this committee, an 
oversight committee, does need to pay some attention to.
I will tell you, Mr. Chairman, on my prior visit here and talking with 
doctors and hospital administrators, who, at that point, had been 
about two months without any mail, no checks in the mail, no cash 
across the counter, no accounts receivable, that they were hurting for 
money.  The bond holders in the great State of New York were asking 
questions; doctors that I talked to were spending their personal 
savings to keep their offices open, to keep their employees hired.
My understanding at the time was there was significant money in the 
so-called disproportionate share of the DSH funds that were 
appropriated, and we concluded the order of the first quarter of fiscal 
year 2006 without those funds being dispensed because there was no 
hospital facility to receive them.  I frankly cannot understand how the 
bureaucracy could not manage to deliver some of that money to the places 
where it was needed.  And I have fought that fight on Capitol Hill by 
myself, it seems like, for the last two months.  So I do welcome this 
marriage and the chance to perhaps finally be able to get that right.
We know FEMA is not a first responder and I do understand that concept, 
but they do have a role in helping with the recovery and the 
aftermath. I think Mr. Stupak correctly noted his frustration with the 
University Hospital versus the HCA facility.  Obviously, someone is 
doing it right.  Obviously someone is falling behind.  I think our 
role as members of this oversight committee needs to be to help the 
people do it right and encourage those who are doing it right.
The issues of consolidation of facilities, that is a local decision.  
That is not a decision for this committee or for the Federal 
government.  But how our funding is going to affect your recovery here 
properly belongs within the purview of this committee, and again, 
Mr. Chairman, I welcome the opportunity to be able to have this 
discussion.
Things as simple as federally qualified health centers might make a 
difference to the new ones.  I have an amendment in our reconciliation 
bill that will allow streamlining for federally qualified health 
centers.  That amendment was pulled at the 11th hour for reasons I 
donï¿½t understand from the conference committee.  I encourage members 
of this committee on both sides to help me with that legislation as 
we start the beginning of next year, helping not only Louisiana, but 
Mississippi and other areas where displaced persons from the storm 
and its aftermath have fled and now have no healthcare in new parts 
of the world.
The notification system that was available for you-all to be able to 
track your patients and where they went and be able to inform 
families, my perception, on the other side of the state line, was 
that it was nonexistent.  And I know my staff spent several days 
trying to locate the infant of a mother who had a recent C-section.  
I rather suspect that story was repeated over and over again as you 
worked your way through those first troubling weeks after the storm.
Mr. Chairman, we are late, but weï¿½re not too late, and I welcome the 
fact we are having this hearing and certainly look forward to hearing 
the testimony today.  
Mr. Whitfield.  Thank you.  Our clock down here is not functioning 
correctly right now, so Iï¿½m going to be observing the five-minute 
rule, if we can.
I recognize Diana DeGette of Colorado for her opening statement.  
Ms. DeGette.  Thank you so much.  I want to echo my colleaguesï¿½ thanks 
for holding this hearing down in New Orleans.  I also want to echo my 
colleaguesï¿½ impressions that touring the city here, there is just no 
way you could know, sitting in Washington or Denver, Colorado, or 
anywhere else, exactly what the citizens of New Orleans continue to 
grapple with every day.
I think it is critical that every Member of Congress come here, and I 
will do my part as a missionary to make sure that happens when we go 
back.  I also think it is critical that we learn from this tragedy 
because there is much that can be learned in other parts of the 
country in dealing with a great crisis like Hurricane Katrina.
Most Americans on a day-to-day basis are not concerned about their 
access to health care.  Daily check-ups for the kids are done at the 
local pediatrician, or the local healthcare clinic will offer flu 
shots, and the hospitalï¿½s are there, if there is a broken bone or if 
surgery is needed.  The elderly are cared for in nursing homes with 
facilities capable of handling their needs, and people with mental 
illness are able to go see their counselors on a regular basis.
This doesnï¿½t always work, but it works for a lot of Americans, and it 
works for a lot of low-income Americans.  But for the poor, there are 
fewer options.  When they donï¿½t have health insurance to pay for the 
care I just talked about, those individuals must find a clinic that 
provides charity care.  So, in many cases, individuals will delay 
treatment before finally going to the emergency room and they will 
delay going to a doctor because they simply donï¿½t have the money.
Yes, there is that safety net, albeit one on tenuous footing.  The 
safety net, by and large, is manned by a lot of the great hospitals, 
like Charity Hospital, throughout the country, and without them, many 
people simply would not have care, resulting in many more deaths.
Now, Mr. Chairman, you take the tenuous footing that we were on for 
our poor patients around the country and in New Orleans, and then you 
add on to it the collapse of the health care infrastructure in New 
Orleans.  No one here can take their healthcare for granted anymore. 
So young or old, black or white, rich or poor, access to adequate 
healthcare is not available.  And as Charity Hospital is closed, are 
as Methodist, Tulane, and the Lindy Boggs Medical Center, even if 
someone is--someone said to me yesterday, if President Bush came here 
and was injured, he would have to go to the emergency room and wait 
24 hours just like everybody else.
And so, it is not a matter of powerful or powerless, or rich or poor. 
We really have issues in this city.  A lot of the discussion today 
will talk about the lessons learned from the hurricanes.  We need to 
talk about preparation for emergency situations and what we can learn, 
but I think what we need to talk about now is how we rebuild the 
medical infrastructure of the region and how we do it quickly.
Three days ago, The New York Times reported that if the 65 percent of 
the regionï¿½s pre-storm population returns by July 1st of this year, 
the city will need to triple the number of hospital beds available.  
That would require hiring 2,500 medical staff members in the next few 
months, finding them housing, and paying them enough to return.  It 
also would mean a tremendous commitment to infrastructure.  So, I 
think this is a crisis that really needs to be addressed right now.
Yesterday, when we visited Charity Hospital and the other hospitals, 
we learned a lot, as you always do when you go on site.  When we saw 
Charity, it was literally, to my mind, frozen in time, although Iï¿½m 
sure it was a lot worse right after the hurricane.  Medical files 
were sitting on tables.  Things had just been left and they are left 
there to this day.  There is no ongoing source of electricity in the 
hospital.  Now, right next door across the street, Tulane is opening 
a medical facility next month.  Charity is still waiting for money 
so that they can start to do the repairs, so they can start to think 
about opening.
We saw in the paper, and I hope our witnesses from Charity will talk 
about the article today, that they are hoping to open some emergency 
facilities by next fall, a year after the hurricane.  Why is this 
happening?
It is happening because Charity has no money to rebuild, and when I 
said, "Why hasnï¿½t FEMA given you money to rebuild" they said, "Well, 
we had to clean out the basement and muck it out ourselves before 
they could give us an estimate."
Now we hear that FEMA said it would cost $26 million to repair 
Charity, and that Charity thinks the cost will be in the nature of 
$258 million.  So, thatï¿½s 10 percent.
You can see that we are still arguing about what is going to happen 
and it is months after the hurricane.  In the meantime, as Mr. Stupak 
said, there is no Level 1 trauma center within a three or four-hour 
drive of New Orleans.
Mr. Chairman, Iï¿½m finishing up, but I want to say, how can we expect 
people to return to New Orleans when there is no Level 1 trauma center?
So, Mr. Chairman, again, I want to thank you for having this hearing.  
There are a lot of issues.  I know we will address some of them today 
and I hope that we will continue to address them on an ongoing basis 
so we can get the facilities up and going again in this city. 
Mr. Whitfield.  Thank you.  At this time we recognize Mrs. Blackburn 
for her opening statement.  
Mrs. Blackburn.  Thank you, Mr. Chairman.  I want to thank you for 
holding the hearing and I would like to thank the Supreme Court for 
your hospitality.  Justice Kimball and I have decided we can speak 
"Southern" to each other.
So, we thank each of you for your hospitality.  We thank all of 
yï¿½all--that is plural for you-all--for being here, because all of 
yï¿½allï¿½s healthcare system--and thatï¿½s plural possessive--needs help. 
I recognize that.
I wanted to specifically recognize our representatives for HCA Corps. 
HCA has over 190 hospitals and 200 outpatients throughout the United 
States.  But most importantly, they are a fine Tennessee company, of 
which we are very proud.  For me, many of their employees and much of 
their activity base is centered in my district.  I would also like to 
mention another constituent company, Life Point Hospitals.  You are 
going to hear a little bit more about them, I understand, from one of 
our representatives.  They are located in Brentwood, Tennessee.  They 
have a facility that was open, up and running and helpful during 
Katrina, and we appreciate their participation and their good work.
Mr. Chairman, today we are going to look at how the healthcare system 
was affected when Katrina hit New Orleans.  One of the things we have 
to realize is this is a regional healthcare area.  I grew up in 
southern Mississippi.  I was there a couple of days after Katrina, I 
was there against last week and I could not believe the activity in 
Laurel, Mississippi, at the little hospital there, where people were 
coming for care because it is not available where they used to go.  
They are running golf carts out in the parking lot.  Who would "athunk" 
such a thing would happen there?  But people are going where they can 
get the services.
Particularly, we will look at how the hospitals prepared for the 
disaster and the actions that took place once the city started 
experiencing the flooding.  Some very important issues that I will be 
discussing with each one of you today are these:  Communication 
disruption, your community and emergency notification systems, power 
availability, your fuel, supplies, your backup systems, electronic 
records, the lack of or the need thereof, your supply shortages, and 
Iï¿½m going to look forward to your testimony.  I hope that we can 
learn a bit more about what went wrong.  You have heard the 
frustration from the other Members that have spoken.  But when 
disasters occur, lessons learned should never have to be relearned. 
We need to remember that.  One of those lessons we should be learning 
is that government agencies have gotten too big, too bloated, too 
bureaucratic and they are too slow to respond.
Last week in Mississippi, I had someone say to me, "There ought to be 
a government law against such and such," pertaining to some of the 
responses to Katrina.  And you know what, ladies and gentlemen?  
They are right.  Iï¿½m sure Mr. Melancon has heard that many times from 
his constituents, because the frustration exists because the Government 
is too big to turn on a dime and respond.  And yes, there is something 
that we can do about it:  We can change the way the system works.
We are looking forward to hearing from you.  Thank you to each one of 
the companies that--the healthcare providers and delivery system here. 
We appreciate the time that you are taking to come before us and be 
our partner in working through this process.  Thank you.
And with that, Mr. Chairman, I yield back the balance of my time. 
Mr. Whitfield.  Thank you.  At this time we recognize Ms. Schakowsky 
of Illinois and her opening statement.  
Ms. Schakowsky.  Thank you, Mr. Chairman and Mr. Stupak, for 
organizing this session here in New Orleans.  I also want to thank 
Congressman Bill Jefferson who spent the day with us yesterday, and 
Congressman Charlie Melancon who has been with us here today.  We 
have been hearing a lot from both of your local representatives about 
what is going on in New Orleans.
Like most of my colleagues, I pretty much scrapped the opening 
statement I had written before because I am now so overwhelmed with 
what I saw yesterday.  You really do have to see it to believe it.
It has just been so incredible to stand there in what were 
neighborhoods filled with tens of thousands of people and there is 
absolutely no one there.
I want to especially thank the health professionals that took us 
around yesterday to see what was going on.  One of the main feelings 
I got was this incredible commitment to serve the people of New 
Orleans that we saw, from the tent facility in the Convention Center 
to the University and Charity Hospitals, where we traipsed around in 
our special protective garb in the basement; the feeling of pain that 
is felt by so many people here in New Orleans that have seen this 
great international city suffering as much as it is; seeing how the 
helipad was created at HCA/Tulane to actually lift people out of here 
was an amazing experience.
I want to congratulate--I saw in the paper, I think it was today, 
that some women are coming to Washington to encourage other Members of 
Congress to come here.  I want to add my voice when I get back to 
Washington.  It is so important for people to be on the ground here 
and see what is going on.  So I certainly wish them well.
Couple of issues I wanted to just raise due to my trip.  One thing I 
found is that the issues are hard to separate.  This is about health 
care today.  But it is very hard to separate health care from housing, 
all the issues facing New Orleans from the housing problem; from 
schools, because people do not want to come back if the schools are 
not operating.  No reimbursement for work, of course, is very 
important the lack of nurses.  Everything is really intertwined, it 
seems to me, in the rejuvenation of New Orleans.
In terms of reimbursement issues and the money issues, I do have to 
say that I was struck, as others have mentioned, by what appeared to 
be a two-tiered system of health care, which I think we do have in 
many ways in our country:  People who can afford it and people who 
canï¿½t.  The dramatic difference between HCA, Tulane, the University 
Hospital, the Charity system, was pretty dramatic, and I think it is 
something that needs to be dealt with here in New Orleans where it is 
so dramatically disparate, and certainly around the country as well.  
But if the Federal government can manage to get the money in hundred-
dollar brick packages that are sent to Iraq, and helping to build the 
hospitals and reconstruction there, it seems to me that in our own 
country, that we could make a priority out of New Orleans and that 
money ought to be flowing here.
Clearly, there are organizational issues, governance issues.  When I 
have asked people who are in charge overall, it is very hard to get an 
answer if there is some center of coordination.
I am concerned about Mardi Gras coming up.  That there was an issue 
raised, and I saw in your paper, that was 2,100 hospital beds, and now 
there are 400 beds between Touro and Childrenï¿½s Hospitals.  Meeting 
this morning with Dr. Leonard Glade from Touro, I understand that 
those beds are not all open because there are not enough nurses to 
serve them.  So, the problem is even worse than it is portrayed.
And the community, in talking about the storm itself, we have been 
talking since September 11 about interoperability of communication 
systems, and yet, so many years later we face that same problem here 
in New Orleans with Katrina.  I think it is time we did something 
about it.  I know that it is not that expensive or hard to do at least 
a make-shift system.  So, I hope we will talk about many of these 
issues and then help to come up with answers and be partners in the 
solution for New Orleans.  Thank you. 
Mr. Whitfield.  Thank you, Ms. Schakowsky.  And before we introduce 
the witnesses, as you probably know, we have two Members of the 
Louisiana delegation in the room right now.  It has already been 
mentioned that Congressman Jefferson has spent a big part of yesterday 
with us, and at this time, we are going to provide opportunities for 
statements by Congressman Melancon and then, Congressman Bobby Jindal. 
So, Congressman you are recognized for an opening statement.  
Mr. Melancon.  Thank you very much to you and Congressman Stupak for 
taking the time to meet with us and to get down to Louisiana.  I wish 
we could put every member of Congress on the ground not only here in 
Louisiana, but also in Mississippi to comprehend the enormity of this 
disaster.  It is unlike anything I have ever seen in my 58 years, and 
I have seen a lot of hurricanes and tornadoes.  We see them on the 
news, but what we see here is nothing like what we thought the pictures 
showed.  It is truly devastating and far more disastrous than anything 
that anybody can imagine.
Just for informational purposes, last week, along with the Mississippi 
delegation, the Louisiana delegation put together a letter to Speaker 
Hastert and Leader Pelosi.  We are asking them to lead a delegation of 
those Members of the House of Representatives that have not put a foot 
in Louisiana or Mississippi.  They need to see, they need to 
understand. When they get back, after they have seen what has happened 
here, if they donï¿½t think that we need help, then there is nothing more 
that I can do.
I think that any human being with a heart and a soul seeing what you 
have seen here in New Orleans, and havenï¿½t seen, I donï¿½t think, yet, 
in Mississippi, it would be quite difficult for you to go back and to 
not try and help these Americans.  They are not Democrats, they are 
not Republicans, they are not rich, they are not poor, they werenï¿½t 
white or black.  They were on the roofs of their houses and devastated 
by the storms.  Any help that Congress can see fit to give--and the 
President included--a helping hand.  We are not asking for handouts, 
we are asking for helping hands.
The Stafford Act is going to need some revisions.  It was designed for 
small disasters, and it doesnï¿½t cover the enormity we have here, much 
less speak to the healthcare issues.  We need to look at, and the 
President needs to look at his executive authority to start waiving 
some of these rules that are out there to make this thing move faster.
As Congresswoman Blackburn said, the Government truly is big and 
enormous.  The problem is FEMA is small and slow and they just donï¿½t 
know how to respond.  We need to make them look at the bigger picture 
and give them more power and authority and probably need to link back 
directly to the President of the United States because they should not 
have to get secretarial sign-offs in order to take actions to move 
something.
As we said, we can mount an attack across the board, across the globe, 
and we have problems getting folks down into disaster areas in a 
meaningful period.  The Medicaid reimbursement, healthcare in general 
has suffered as have all of the infrastructures in South Louisiana and 
South Mississippi.
One of the things that a lot of people donï¿½t understand, particularly in 
Congress, in Louisiana, through the years, there has been protection 
given to funding of certain programs and areas of Government that 
Government takes care of because of concerns by people that receive 
Government funding.  The irony is that the two elements of the 
infrastructure that are left as the ones subject to the budget cuts 
when times get bad are healthcare and education, two of the most 
important elements of any community, any State, any region.  That has 
been what has been happening.  This State legislature and Government 
have cut approximately $1 billion because there wasnï¿½t the ability to 
do bond issues to support such operations.
We are truly in a dilemma.  Some people will be critical of Louisiana, 
but I can tell you that we are doing everything that can be done within 
the constitutional confines that create problems for us in each State.
If I had to recommend to people how can we help ourselves get out of 
this:  Waive the rules, amend the Stafford Act, provide for legislation 
that would let Louisiana, like all interior States, share in our Outer 
Continental Shelf revenue sharing.  The country receives approximately 
$8.5 billion a year in revenue sharing from minerals, coal, oil, gas, 
et cetera, across this great country off of Federal land and our Outer 
Continental Shelf.  Those that are interior States share at a rate of 
50 percent.  Louisiana gets zero.
We also provide $6 billion dollars of $8 and a half billion to the U.S. 
Treasury.  If we can get our share like the interior States do, we can 
help ourselves in many ways and we would not have to continue to beg and 
grovel to the Congress and to have--you wouldnï¿½t have to worry about, 
every year, getting appropriations.
So, I appreciate the opportunity that you have allowed me to be here.  
I especially appreciate the fact that you are here.  And people of 
Louisiana, believe me, they are very, very appreciative of you taking 
the time from your busy schedules.  Thank you. 
Mr. Whitfield.  Thank you very much for that statement, and we 
appreciate you being here and the hard work that you are doing in 
Congress to assist.
At this time, we recognize Congressman Jindal for his statement. 
Mr. Jindal.  Thank you.  I want to thank you and the members of the 
committee for taking the time to come down here.  Like my colleague, 
Mr. Melancon, I do believe that the more our colleagues get to see with 
their own eyes the devastation on the ground, the easier it will be to 
comprehend the amount of work that needs to be done to rebuild this 
great city, not only for Louisiana but the country, not just here, but 
there are areas across southwest and central Louisiana that were also 
devastated.
Mr. Chairman, I particularly welcome you back.  I know it was really 
just months ago you were here where we had the opportunity to visit on 
healthcare just several months ago.  For the members of the committee, 
I do have a special interest in healthcare.  I had the privilege before 
I joined you in Congress as serving as Louisianaï¿½s Secretary of the 
Department of Health and Hospitals.  I had the privilege of coming to 
Washington, having discussions with the Assistant Director of the 
bipartisan Medicaid Commission you created and then serving as 
Assistant Secretary with Tommy Thompson.
So, I especially am passionate about the issue you are here to discuss, 
which is healthcare and in particular, hospitals.  You know, I think 
one of the greatest needs as we try to encourage people to return and 
resume their normal lives is the need to restore a safety net, to 
restore formal critical healthcare services.  I know you are also here 
to focus on the continued operations of hospitals and disasters in the 
future and make sure we ensure the safety of patients who entrust 
their care to these facilities.
Clearly, we need to do more in terms of the planning for evacuation, 
continuity of care for patients already in facilities, as well as 
protecting the hospitals so they can play a role in emergency medical 
treatment, as well as relief for those that are stranded.  During 
Hurricane Katrina only a handful of hospitals in the greater New 
Orleans region were able to continue operating during the storm and 
its aftermath.  Quite literally, these buildings were buffeted by 
winds.  Flooding knocked out the cityï¿½s entire electrical grid, 
cutting power to those hospitals along with everything else.  In 
these hospitals, you had patients, you had nurses, you had doctors, 
you had dedicated staff who endured heat, no electricity, and 
limited communication.  To make matters worse, not all of these 
hospitals in the flood zones had emergency generators.  Not all of 
them had field supplies.  Many of them did have them but they were 
located on lower floors or in basements, and therefore, had outages 
due to flooding.
As a result of the primary power failure, in many cases, you had the 
loss of backup power as well, yet hospital staffers were called upon 
to perform life-saving efforts such as hand-bagging respiration 
continuously, for hours, until they could evacuate their patients, and 
truly, those were some of the unsung heroes of this tragedy, these 
dedicated workers who stayed by the bedsides of their patients, asking 
for additional assistance and rescue.  Some of the most heartbreaking 
calls--we provided all the help we could, providing information to the 
forces on the ground in order to facilitate aid for those stranded in 
the hospitals, and the rescuers sometimes found themselves climbing 
floors to avoid the rising waters.
I will close, and I want to introduce one of the members of the panel. 
Iï¿½m very honored to be able just to take a little bit of your time.  
I know it is an exception to the normal rules of the committee and 
subcommittee, so I thank the Chairman for his indulgence.
And I want to echo, as my colleague said, and I very much appreciate 
your taking the time to come see this.  Many of the Members have been 
here before, and we appreciate your willingness to come and see this 
for yourself.  I want to thank the staff as well for spending their time 
here as well.
I want to close by introducing one of the members of your distinguished 
panel.  One of the men in the heart of the disaster, who fought hard to 
keep his hospital operational and patients safe, and heï¿½s sitting here 
today, and that is Mr. Gary Muller.  He is the President and Chief 
Executive Officer of West Jefferson Medical Center.  That is one of the 
hospitals that stayed open during the storm and continued to stay open 
and continued to operate.  Mr. Muller is the immediate past chairman of 
the Louisiana Hospital Association.  He recently received Louisianaï¿½s 
Senior Level Health Healthcare Executive Regentï¿½s Award for 2004 from 
the American College of Healthcare Executives.
You have got his biography in front of you.  I wonï¿½t go through all of 
his particulars, but I do want to say that is a well-deserved honor, 
when you consider his staffï¿½s and his medical centerï¿½s extraordinary 
performance and what they did under his leadership during the 
extraordinary circumstances of Hurricane Katrina and Rita.
I want to thank you in advance, and I know when we come back to 
Congress, it is widely anticipated that the House will concur with 
something the Senate majority approved, which is something your 
committee played a critical role in, in providing substantial relief 
to Louisianaï¿½s Medicaid program.  I want to thank you for that because 
that will go a long way to mitigating some of those cuts that Charlie 
Melancon talked about.  Nearly $2 billion from the Gulf Coast, nearly 
half of that coming from the State of Louisiana.  That is absolutely 
critical in giving the State the time it needs to reorganize its 
healthcare services.
Mr. Chairman and members of the committee, thank you for allowing 
Charlie and I to be here.
Mr. Whitfield.  Thank you very much for your statement, and we 
appreciate your leadership in the Congress on necessary healthcare 
issues.
With that, I will just dismiss the two of you, and we look forward to 
hearing the testimony of our panel.  So, thank you all very much for 
being here.
At this time, it gives me great pleasure to introduce our first panel.  
First of all, we have Mr. Mel Lagarde, who is the President and CEO of 
HCA Delta Division.  Second of all, we have Mr. James Montgomery, who 
is the President and Chief Executive Officer of Tulane University 
Hospital and Clinic.  Third we have Mr. Rene Goux, Chief Executive of 
Memorial Hospital and Tenet Healthcare Corporation.  Fourth, we have 
Mr. Robert Smith, who is Senior Vice President of Regional Operations 
for Texas/Gulf Coast Tenet Healthcare Corporation.  We have Dr. Cathi 
Fontenot, who is Medical Director at the Medical Center of Louisiana, 
and we spent some time with her yesterday.  Dr. Donald Smithburg, who 
is Executive Vice President of the LSU system, Chief Executive Officer 
of the LSU Healthcare Services Division.  We spent some time with him 
yesterday.  And then, Mr. Jon Sewell, who is the Chief Executive 
Officer of Chalmette Medical Center, University Health Services 
Corporation, and then, Bobby Jindal has already introduced Mr. Muller, 
but Gary Muller, who is the President and Chief Executive Officer of 
the West Jefferson Medical Center.
Before I proceed with you all, I do want to ask unanimous consent. We 
have a letter here given to us by the President of the Louisiana State 
University System, William Jenkins, who was also with us yesterday and 
we want to introduce this into the record.  I think you have got a copy 
of this, Mr. Stupak.
Without objection, so entered. 
[The information follows:]

Mr. Whitfield.  I want to remind all of you, we are holding an 
investigative hearing.  When doing so, it is our practice to take 
testimony under oath.  Do you have any objection to testifying under 
oath this morning?  I would advise you that under the rules of the 
House, and the rules of the committee, you are entitled to be advised 
by legal counsel, and I would ask:  Do any of you desire to be advised 
by legal counsel today?
In that case, if you would all rise and raise your right hand, I would 
like to swear you in.
[Witnesses sworn.] 
Thank you, you are now under oath, and Mr. Lagarde, we call on you to 
begin with your five minute opening statement.

TESTIMONY OF MEL LAGARDE, PRESIDENT AND CEO OF HCA DELTA DIVISION, HCA 
INC.; JAMES T. MONTGOMERY, PRESIDENT AND CHIEF EXECUTIVE OFFICER, 
TULANE UNIVERSITY HOSPITAL & CLINIC, HCA, INC.; RENE GOUX, CHIEF 
EXECUTIVE OFFICER, MEMORIAL MEDICAL HOSPITAL, TENET HEALTHCARE 
CORPORATION; ROBERT SMITH, SENIOR VICE PRESIDENT, REGIONAL OPERATIONS-
TEXAS/GULF COAST, TENET HEALTHCARE CORPORATION; CATHI FONTENOT, MEDICAL 
DIRECTOR, MEDICAL CENTER OF LOUISIANA-NEW ORLEANS; DONALD R. SMITHBURG, 
EXECUTIVE VICE PRESIDENT-LSU SYSTEM, CHIEF EXECUTIVE OFFICER, LSU 
HEALTHCARE SERVICES DIVISION; JON SEWELL, CHIEF EXECUTIVE OFFICER, 
CHALMETTE MEDICAL CENTER, UNIVERSAL HEALTH SERVICES, INC.; AND A. GARY 
MULLER, PRESIDENT AND CHIEF EXECUTIVE OFFICER, WEST JEFFERSON MEDICAL 
CENTER

Mr. Lagarde.  Good morning.  I am President of HCA Delta Division, 
which encompasses Louisiana and Mississippi.  Headquartered in 
Nashville, HCA is the largest private healthcare provider in the United 
States.  As Delta Division President, I have taken an active part in 
formulating our comprehensive strategy on emergency preparedness.  As a 
former hospital CEO, I have come to appreciate the critical importance 
of preparation for all types of disasters.  In the wake of Hurricane 
Katrina, I have acquired first-hand experience in amending and 
modifying that strategy.  We created the Disaster Readiness Manual, 
which serves as a comprehensive reference for our hospitals.
Ever since our inception in 1968, HCA has taken seriously our 
responsibility for emergency preparedness and response.
Historically, the Joint Commission on Accreditation of Healthcare 
Organizations has served as the national survey and standards agency 
for accreditation based upon quality and patient safety.  JCAHO 
accreditation represents, in part, that accredited hospitals have 
designed, implemented, and demonstrated the efficacy and compliance of 
the emergency preparedness plans of accredited institutions.  All HCA 
hospitals have full JCAHO accreditation, based in part upon compliance 
with the organizationï¿½s emergency preparedness standards.  Particularly 
motivated by the events of September 11, HCA has scrutinized and 
enhanced its comprehensive strategy toward emergency preparedness. HCA 
is looking to enhance not only the emergency preparedness of each 
affiliated hospital, but also the emergency preparedness of the entire 
HCA network, and most importantly, the communities served by HCA 
affiliates.  In designing our approach, working in conjunction with the 
CEO of each HCA facility, we began by assessing the emergency 
preparedness of our affiliates.  HCA also conducted facility audits to 
ensure data quality and accuracy.  We then met with the departments of 
health of various States, JCAHO, and the American Hospital Association 
to develop community-based emergency preparedness strategies.
On the Federal level, HCA met with the Department of Health and Human 
Services, Office of Emergency Preparedness, to discuss the role that 
HCA Resource Deployment could play in national emergency preparedness 
plans.  HCA also was among the first private-sector entities to meet 
with officials at the Department of Homeland Security shortly after 
Congress had established the agency.  HCAï¿½s Delta Division encompasses 
Louisiana and Mississippi.  As Delta Division President, I have taken 
an active part in formulating HCAï¿½s comprehensive strategy on 
emergency preparedness.  As a former hospital CEO, I have come to 
appreciate--both professionally and personally--the critical importance 
of preparedness for all types of disasters.
In the wake of Hurricane Katrina, I have also acquired firsthand 
experience in implementing and modifying that strategy.  Before I 
delve into my experiences in preparing for and managing emergency, 
however, I would like to provide you with some background information 
on the structure of HCA.  I believe that this information will help 
you appreciate the interconnections between the emergency preparedness 
plans of HCA affiliates, the communities served by HCA hospitals and 
the HCA network.
One. Community Based Emergency Preparedness Strategies.
Hospitals are community institutions, where people turn for care and 
solace in times of crisis.  September 11 and the anthrax attacks 
underscored the need for hospitals to be cognizant of disasters within 
the communities they serve and the special risks that such service 
entails.  And in an era of terrorism, hospitals no longer can afford to 
be isolated from each other or from governmental agencies.  Rather, 
these parties must form a seamless web in order to formulate a coherent 
emergency response and to educate the community on emergency 
preparedness.
HCA encourages all affiliates to contribute and comply with their 
community-based emergency preparedness plan.  HCAï¿½s participation also 
enables employees to serve on disaster medical assistance teams, which 
may be deployed anywhere in the United States to support communities 
overwhelmed by emergency.
HCA also encourages affiliates that currently are located outside 
affected areas to coordinate with local and State agencies to ensure 
that appropriate emergency preparedness plans are developed for their 
communities.  Additionally, HCA affiliates serve as participants in the 
National Disaster Medical System, prepared to receive disaster victims 
in the event that a mass casualty situation arises.
HCA currently sponsors two DMATs, one based in Atlanta, Georgia, 
omprising 125 members, and another based in Denver, Colorado, 
comprising 127 members.  HCAï¿½s director of emergency preparedness 
commands the Georgia-based team, which was deployed to New York after 
the September 11 attacks, and to the Gulf Coast after Hurricane 
Katrina. HCA staff members also lead the Colorado based DMAT.  In both 
cases, HCA acts as a resource for the DMATs by recruiting new members, 
arranging training, and coordinating deployment.  HCA also provides 
material support in the form of pharmaceuticals, communications 
equipment, defibrillators, protective gear, vehicle rentals for 
training exercises and storage space.
HCAï¿½s leadership believes that affiliates should take an active role in 
educating their communities on emergency preparedness.  To help 
affiliates assume these educational responsibilities, we have provided 
them with materials such as posters, web casts, seminar programs, and 
conference programs.  One example of the materials that we have 
distributed is entitled "General Guidelines for the Recognition, 
Immediate Treatment, and Precautions in the Management of Potential 
Victims of Radiological, Biological, or Chemical Exposure."  Our 
internal emergency preparedness manual, entitled Disaster Readiness, 
Guidelines for Emergency Management Planners, is another example of the 
materials that we distribute.  HCA has mailed copies of disaster 
readiness to State hospital associations, the HHS-OEP, the Centers for 
Disease Control, JCAHO and to education programs aimed at healthcare 
professionals.
I am proud to note that HCA personnel served as members of the DMAT 
deployed to ground zero in the immediate aftermath of the events of 
September 11.  Additionally, HCA personnel at one of our affiliate 
hospitals in Florida diagnosed and treated the first anthrax victims.  
Two.  Enhancing the Emergency Preparedness of the HCA Network.
In addition to participating in community-based emergency planning, HCA 
has taken steps to enhance the emergency preparedness of the HCA 
network.  For example, HCA has created the Disaster Readiness Manual, 
which is updated annually, to serve as a comprehensive reference for 
our affiliated hospitals.  The manual explains the hospital emergency 
incident command system, which we require affiliates to adopt.  I will 
speak more about HEICS later, in which I will detail HCAï¿½s attempts to 
strengthen the emergency preparedness of affiliates.  In addition to 
describing the HEICS, the Disaster Readiness Manual provides affiliates 
with templates of specific plans dealing with natural disasters, 
bioterrorism, chemical terrorism, and radiation sickness.  HCA requires
affiliates to implement and customize these templates as appropriate. 
A chief nursing officer is designated for each division and is 
responsible for making sure that the hospitals under their supervision 
comply with the manualï¿½s policies.  We also train affiliate CEOs and 
CNOs in disaster readiness through web cast, conference calls, and 
facility-specific customized training.
As part of our emergency preparedness guidance, HCA provides each 
hospital with an algorithm to calculate the quantity of drugs, 
supplies, and equipment that would be needed in a crisis situation. 
Factors of computation include:  one, size; two, medical staff support; 
and, three, patient census trends among others in the various markets.  
We utilize these calculations toward emergency preparedness against all 
kinds of hazards, whether natural or man made.
Although HCA expects each affiliate to maintain emergency supplies of 
pharmaceuticals and medical call equipment, we recognize that a 
catastrophic event could cause affiliates to exhaust provisions quickly 
without hope of restocking from older suppliers.  HCA has, therefore, 
created the central supply warehouse system, which is devoted to storing 
drugs and medical supplies vital to the natural emergency response.  The 
warehouse system requires each division to set up a central supply 
center containing caches of burn/trauma kits, SARS/respirator kits, and 
pharmaceutical kits.  The Far West and the East Florida divisions are 
responsible for storing bio-isolation units.  Additionally, HCA has 
developed the capacity to transport kits and bio-isolation units to any 
affiliate hospital within 24 hours.
HCA also recognizes that affiliates responding to catastrophic events 
may confront insufficient personnel to treat the number of incoming 
patients.  We, therefore, have relied on one of our subsidiaries, All 
About Staffing, to augment the emergency response capabilities of our 
affiliates.  Whenever an emergency occurs, AAS is ready to provide 
temporary staffing for affected facilities.  AAS generally provides 
nursing support, although an affected facility, we had any type of 
staff essential to fulfilling patient needs.  HCA has appreciated the 
Federal governmentï¿½s waiving of licensure requirements after 
declarations of emergency.  HCA believes that these waivers have 
enhanced our ability to draw upon staff throughout our network in 
response to emergencies of national dimensions.
So far, I have been speaking to you about how HCA has attempted to 
enhance network response to emergencies.  Now I would like to speak 
briefly about HCA efforts to prevent catastrophic events.  Throughout 
the HCA hospital network, we conduct syndromic surveillance of 
emergency room patients with laboratory testing needs.  For example, 
HCA monitors the white blood cell volume of such patients daily.  Our 
surveillance has been instrumental in identifying increased rates of 
influenza in the communities that our affiliates serve.  We believe 
that our syndromic surveillance system may be helpful in identifying 
the spread of other diseases of national import.  Currently, CDC is 
considering the role that HCA may play in national surveillance 
through the CDC syndromic surveillance program.
Three.  Strengthening the Emergency Preparedness of HCA Affiliates.
HCA has taken steps to strengthen the emergency preparedness of our 
affiliates, as they inevitably are on the front lines of catastrophic 
events.  As I mentioned previously, HCA requires affiliates to adopt 
the hospital emergency incident command system.  There are two reasons 
for this requirement.  First, HEICS creates a common vocabulary for 
use during an emergency response.  HCA has also encouraged other 
healthcare providers to utilize HEICS, because we believe that more 
widely expressed use would ensure better coordination among first 
responders in every community.  Second, HEICS creates a framework of 
leadership positions, and assigns specific responsibilities to those 
positions.  The HEICS command structure establishes an "all hazards" 
command structure within the hospital, which links with the "community" 
command structure--whether that "community" comprises the neighborhoods 
in proximity to the hospital, our other HCA divisions, other local 
hospitals, or corporate offices.
HEICS therefore creates fully operational chains of command at the 
first sign of an emergency.  Such command chains include the hospital 
experiencing the events, the division and market where that hospital 
is situated, the CSC associated with that division and HCA corporate 
headquarters.  Although HCA sister facilities are not direct links in 
the command chain, they stand ready to provide support, using HEICS 
as a shared platform.
As I mentioned previously, HEICS has the benefits of providing a common 
vocabulary, role definition and organizational structure, and 
accountability.  Accordingly, the system has the ability to supersede
corporate titles and business positions that establish the traditional 
lines of authority during nonemergency situations.
As part of our quality review system, every 12 to 24 months, HCA 
conducts routine audits and surveys of the emergency preparedness of 
each affiliate hospital.  While HCA data collection demonstrates that 
affiliates steadily are improving their programs, HCA continues to use 
QRS to ensure that facilities comply with the disaster readiness 
guidelines.
Four. HCA Response to Hurricane Katrina.
HCA has been in operation since 1968 and we often must contend with 
hurricanes and other natural disasters.  In 2004 alone, HCA affiliates 
in Florida were exposed to four major storms, including the devastating 
effects of Hurricanes Charlie, Frances, and Ivan.  Needless to say, 
severe weather preparedness is a top priority for our HCA affiliates in 
the southeast.  Accordingly, in November of 2004, HCA senior executives 
and the CEOs of our affiliate hospitals met in Orlando, Florida, to 
discuss "Hurricane lessons learned."
The meeting helped HCA identify three areas in our severe weather plan 
that needed improvement:  one, communication; two, transportation of 
supplies; and three, sourcing for alternative energy should public 
utilities fail.  In the following months, HCA provided our affiliates 
with satellite phones, hurricane shutters, and additional portable 
emergency generators.  HCA also contracted with local businesses--like 
refrigeration companies, water companies, and diesel and gasoline 
retailers--to provide supplies quickly in the face of an emergency.  In 
hurricane strike zones, we began to move food, medical supplies, and 
other gear to warehouses near hospitals.
Despite this extent of experience and preparation, Hurricane Katrina 
inflicted an unprecedented level of destruction on the region, which 
affected our HCA affiliates in Louisiana and Mississippi.  Lakeview 
Regional Medical Center in Covington, Louisiana, sustained weather and 
wind damage but remained open.  Garden Park Medical Center in Gulfport,
Mississippi, sustained flooding and roof damage, but resumed emergency 
room operation shortly after Hurricane Katrina passed.  Since Garden 
Park Medical Center was one of only two hospitals still functioning in 
the Gulfport-Biloxi area after Hurricane Katrina, FEMA installed tents 
near its parking lot to give tetanus shots and to treat the less 
seriously injured.
HCA was forced to evacuate two facilities.  We closed Tulane-Lakeside 
Hospital in Metairie, Louisiana, after local officials ordered a 
mandatory evacuation, and we transported patients, employees, and family 
members to a safe location by bus convoy.  Tulane University Hospital 
and Clinic in New Orleans, Louisiana, which sustained the heaviest 
damage, mainly had to be evacuated by helicopter.
I would like to speak now of HCAï¿½s role in the TUHC evacuation and in 
the national emergency response to Hurricane Katrina.
On August 29, 2005, Hurricane Katrina made landfall in Louisiana as a 
Category Four storm.  Shortly after Katrina passed, CEO Jim Montgomery 
reported that TUHC had suffered only minor damage and that flooding in 
New Orleans appeared to be limited.  Our relief was short-lived, 
however.  By the morning of August 30, we became painfully aware of the 
true state of devastation caused by Hurricane Katrina.
 HCA senior executives already had established an HEICS command center 
 in the board room of the companyï¿½s headquarters in Nashville, the 
 corporate Company Command Center, and they remained there for the rest 
 of the week to coordinate HCA disaster relief efforts along the Gulf 
 Coast.
The Corporate Command Centerï¿½s top priority was to assist in the 
evacuation of TUHC in any way possible.  On the morning of August 30, 
the TUHC command center reported that flooding had intensified in New 
Orleans and was threatening the hospitalï¿½s emergency generators.  At 
that point, TUHC housed approximately 180 patients and 1,000 staff 
members and their families.  Eleven patients were on ventilator 
support, and two were attached to heart pumps.  It was clear that TUHC 
had to be evacuated as soon as possible.  Although TUHC had called 
Acadian Ambulance to request helicopter assistance, we did not believe 
that Acadian alone could complete the evacuation within a reasonable 
period of time.  HCA therefore chartered 24 helicopters to support 
TUHC efforts.
On the morning of August 31, the Corporate Command Center learned that 
HCA-chartered helicopters had arrived at TUHC, with the HCA contractors 
providing flight coordination.  Since the TUHC evacuation proceeded in 
stages, HCA headquarters arranged to load each chartered helicopters 
with 750 pounds of food, water and medical supplies to help TUHC staff 
and patients remaining in New Orleans.  Rather than transporting 
patients from one staging area to the next, the Corporate Command 
Center prearranged for other HCA facilities to be awaiting their 
reception.  Many of the evacuees initially were taken to Womenï¿½s and 
Childrenï¿½s Hospital in Lafayette, Louisiana.  HCA sent 50 nurses from 
AAS to support affiliated hospitals in the Gulf Coast receiving 
evacuees, and we stood ready to deploy 170 additional nurses, if 
needed.  On the evening of August 30, TUHC lost backup power causing 
the communications network to fail.  The following morning, 
headquarters helped TUHC set up a radio network by flying in three 
members of the Tallahassee Amateur Radio Club, who set up a portable 
generator-powered HAM radio with a satellite uplink.  The three radio 
operators used the satellite uplink to contact HCA offices in 
Tallahassee, Florida, for evacuation information.  They then used 
two-way radios to relay evacuation information to TUHC staff.  The 
three radio operators also delivered flight directions from HCA 
staff to the helicopter pilots.
On September 1, TUHC completed the evacuation of its patients, 
along with 38 patients from Charity Hospital.  The Corporate Command 
Center was encouraged by our hospitalï¿½s response to the greatest 
natural disaster in our nationï¿½s history.
Apart from my account of the evacuation itself, let me now give you 
a sense of the magnitude of HCAï¿½s response to Hurricane Katrina.  In 
terms of supplies, HCA provided the following to aid Katrinaï¿½s 
victims:  30,000 gallons of bottled water; 95,600 pounds of ice; 
30,320 meals ready to eat; 5 truckloads of other food; 4 truckloads of 
linen; 1 truckload of scrubs; 7 truckloads of assorted supplies; 
1 truckload of mattresses; 2,500 gallons of gasoline for vehicles and 
small portable generators; and 50,000 to 100,000 gallons of diesel 
fuel for large portable generators.  In terms of pharmaceuticals, HCA 
provided 17,360 doses of Cipro, tetanus immunizations and insulin 
injections, along with other drugs.
To serve transportation needs, HCA provided 24 chartered helicopters 
for patient evacuation, as well as one fixed-wing plane to deliver 
supplies, two Boeing 727s to transport staff and families to Houston 
and Atlanta, 200 commercial airline tickets, five buses for 
evacuations, and one refrigeration truck.
In terms of communications, HCA provided cell phones and 15 satellite 
phones.  Finally, HCA sponsored the Georgia-based DMAT response to 
Hurricane Katrina.  We traveled 1,400 miles to set up a mobile hospital 
in Galveston, Texas.  That DMAT team provided medical assistance to 
4,000 evacuees, nearly all of whom were at least 65 years old.
HCAï¿½s efforts to help victims of Hurricane Katrina are continuing 
today.  HCA established the HCA Hope Fund and contributed $4 million, 
also offering to match employee donations dollar for dollar.  HCAï¿½s 
hospital business partners and vendors, including the Rapides Foundation, 
St. Davidï¿½s Foundation, Health One, the Methodist Foundation and 
Meditech, have contributed a total of $1.5 million.  HCA affiliates 
throughout the Nation and our employees have donated an additional 
$450,000 to the fund.  Displaced HCA employees continue to be on 
payroll and HCA has offered to help them relocate, either temporarily 
or permanently, within the HCA network.  Moreover, the HCA Hope Fund 
gave $1.5 million in grants to help displaced employees meet immediate 
living expenses.  We also have donated $1 million to the American Red 
Cross.  Finally, HCA has shown dedication to New Orleans by reopening 
Tulane Lakeside Hospital, and by moving forward with the recovery 
process at TUHC.
V. Lessons Learned From Hurricane Katrina.
Since grappling with the effects of Hurricane Katrina last summer, HCA 
is continuing the process of analyzing our procedures for emergency 
preparation and response, continually seeking to enhance our practices 
and procedures.  For example, in March 2006, HCA headquarters will host 
a lessons learned meeting, which will be attended by each of our 
affiliate hospitals that experienced hurricane and other natural 
disasters during 2005.  In the meantime, HCA is working with its 
affiliates to assess the positions of emergency generators and to 
enhance their communications capabilities.  In addition, our current 
efforts to improve upon preparedness are focusing on meetings, 
preparation, response, and relief for Avian flu.  On balance though, 
I believe that the HCA response to Hurricane Katrina revealed far more 
strengths than weaknesses in our emergency preparedness strategy.  On 
the community level, HCA was able to relay critical information to 
TUHC and Federal authorities after the hospitalï¿½s communications 
systems failed.  Garden Park Medical Center in Gulfport, Mississippi 
coordinated with FEMA to determine how to treat less seriously injured 
victims of Katrina.  On the network level, HCA successfully created a 
command chain and drew upon the resources of all our affiliates to 
evacuate TUHC, to provide placement for all TUHC patients, and to 
provide food, water, and medical supplies as needed.  On the affiliate 
level, TUHC followed the Disaster Readiness Manual and developed an 
effective emergency preparedness plan.  At all levels, therefore, HCA 
launched an appropriate response to Hurricane Katrina.
In sum, we are justly proud of our colleagues at TUHC, as well as all 
190,000 members of our staff and the communities that we serve.
Thank you, Mr. Chairman, and members of the committee, for your time and 
attention.  I will be happy to respond to any questions. 
[The prepared statement of Mel Lagarde follows:]
Prepared Statement of Mel Lagarde, President and CEO of HCA Delta 
Division, HCA Inc.

Mr. Chairman, members of the Committee and staff - good morning.  My 
name is Mel Lagarde, and I am the Delta Division President of HCA, Inc. 
("HCA").  HCA is the largest private healthcare provider in the United 
States.  Headquartered in Nashville, Tennessee, HCA affiliates operate 
180 hospitals and eighty-two outpatient surgery centers in twenty-three 
states, England, and Switzerland.  HCA facilities currently employ 
approximately 190,000 people worldwide.  Ever since our inception in 
1968, HCA has taken seriously our responsibility for emergency 
preparedness and response.
Historically, the Joint Commission on Accreditation of Healthcare 
Organizations ("JCAHO") has served as the national survey and standards 
agency for accreditation based upon quality and patient safety.  JCAHO 
accreditation represents, in part, that accredited hospitals have 
designed, implemented and demonstrated the efficacy and compliance of 
the emergency preparedness plans of accredited institutions.  All HCA 
hospitals have full JCAHO accreditation, based in part upon compliance 
with the organizationï¿½s emergency preparedness standards.  Particularly 
motivated by the events of September 11th, HCA has scrutinized and 
enhanced its comprehensive strategy towards emergency preparedness. HCA 
is looking to enhance not only the emergency preparedness of each 
affiliated hospital, but also the emergency preparedness of the entire 
HCA network, and most importantly, the communities served by HCA 
affiliates.
In designing our approach, working in conjunction with the CEO of each 
HCA facility, we began by assessing the emergency preparedness of our 
affiliates.  HCA also conducted facility audits to ensure data quality 
and accuracy.  We then met with the Departments of Health of various 
states, JCAHO, and the American Hospital Association ("AHA") to develop 
community-based emergency preparedness strategies.  On the federal 
level, HCA met with the Department of Health and Human Services, Office 
of Emergency Preparedness ("HHS-OEP") to discuss the role that HCA 
resource deployment could play in national emergency preparedness plans. 
HCA also was among the first private sector entities to meet with 
officials at the Department of Homeland Security ("DHS"), shortly after 
Congress had established the agency.
HCAï¿½s Delta Division encompasses Louisiana and Mississippi.  As Delta 
Division President, I have taken an active part in formulating HCAï¿½s 
comprehensive strategy on emergency preparedness.  As a former 
hospital CEO, I have come to appreciate - both professionally and 
personally - the critical importance of preparedness for all types of 
disasters.  In the wake of Hurricane Katrina, I also have acquired 
first-hand experience in implementing and modifying that strategy.  
Before I delve into my experiences in preparing for and managing 
emergencies, however, I would like to provide you with some 
background information on the structure of HCA.  I believe that this 
information will help you appreciate the interconnections between 
the emergency preparedness plans of HCA affiliates, the communities 
served by HCA hospitals, and the HCA network.

I.	Community-Based Emergency Preparedness Strategies
Hospitals are community institutions, where people turn for care and 
solace in times of crisis.  September 11th and the anthrax attacks 
underscored the need for hospitals to be cognizant of disasters 
within the communities they serve, and the special risks that such 
service entails.  And in an era of terrorism, hospitals no longer can 
afford to be isolated from each other, or from governmental agencies.  
Rather, these parties must form a seamless web in order to formulate a 
coherent emergency response and to educate the community on emergency 
preparedness.
HCA encourages all affiliates to contribute and comply with their 
community-based emergency preparedness plan.  HCAï¿½s participation also 
enables employees to serve on Disaster Medical Assistance Teams 
(DMATs), which may be deployed anywhere in the United States to support 
communities overwhelmed by emergency.  HCA also encourages affiliates 
that currently are located outside affected areas to coordinate with 
local and state agencies to ensure that appropriate emergency 
preparedness plans are developed for their communities.  Additionally, 
HCA affiliates serve as participants in the National Disaster Medical 
System ("NDMS"), prepared to receive disaster victims in the event 
that a mass casualty situation arises.
HCA currently sponsors two DMATs - one based in Atlanta, Georgia 
comprising 125 members, and another based in Denver, Colorado 
comprising 127 members.  HCAï¿½s Director of Emergency Preparedness 
commands the Georgia-based team, which was deployed to New York after 
the September 11th attacks, and to the Gulf Coast after Hurricane 
Katrina.  HCA staff members also lead the Colorado-based DMAT.  In both 
cases, HCA acts as a resource for the DMATs by recruiting new members, 
arranging training, and coordinating deployment.  HCA also provides 
material support in the form of pharmaceuticals, communications 
equipment, defibrillators, protective gear, vehicle rentals for 
training exercises, and storage space.
HCAï¿½s leadership believes that affiliates should take an active role in 
educating their communities on emergency preparedness.  To help 
affiliates assume these educational responsibilities, we have provided 
them with materials such as posters, web casts, seminar programs, and 
conference programs.  One example of the materials that we have 
distributed is entitled General Guidelines for the Recognition, 
Immediate Treatment, and Precautions in the Management of Potential 
Victims of Radiological, Biological, or Chemical Exposure.  Another 
example is our internal emergency preparedness manual, entitled 
Disaster Readiness: Guidelines for Emergency Management Planners.  HCA 
has mailed copies of Disaster Readiness to state hospital associations, 
the HHS-OEP, the Centers for Disease Control ("CDC"), JCAHO, and to 
educational programs aimed at healthcare professionals.  I am proud to 
note that HCA personnel served as members of the DMAT deployed to 
Ground Zero in the immediate aftermath of the events of September 11th. 
Additionally, HCA personnel at one of our affiliate hospitals in 
Florida diagnosed and treated the first anthrax victims.

II.	Enhancing the Emergency Preparedness of the HCA Network
In addition to participating in community-based emergency planning, 
HCA has taken steps to enhance the emergency preparedness of the HCA 
network.  For example, HCA has created the Disaster Readiness manual, 
which is updated annually, to serve as a comprehensive reference for 
our affiliated hospitals.  The manual explains the Hospital Emergency 
Incident Command System ("HEICS"), which we require affiliates to 
adopt.  I will speak more about HEICS later, when I detail HCA attempts 
to strengthen the emergency preparedness of affiliates.  In addition 
to describing HEICS, the Disaster Readiness manual provides affiliates 
with templates of specific plans dealing with natural disasters, 
bioterrorism, chemical terrorism, and radiation sickness.  HCA requires 
affiliates to implement and customize these templates as appropriate. 
A Chief Nursing Officer is designated for each Division and is 
responsible for making sure that the hospitals under their supervision
comply with the manualï¿½s policies.  We also train affiliate CEOs and 
CNOs in Disaster Readiness through web cast, conference calls and 
facility-specific customized training.
As part of our emergency preparedness guidance, HCA provides each 
hospital with an algorithm to calculate the quantity of drugs, 
supplies and equipment that would be needed in a crisis situation.  
Factors of computation include:  (i) staff size; (ii) medical staff 
support; and (iii) patient census trends, among others in the various 
markets.  We utilize these calculations to achieve emergency 
preparedness against all kinds of hazards - whether natural or 
man-made.
Although HCA expects each affiliate to maintain emergency supplies of 
pharmaceuticals and medical equipment, we recognize that a catastrophic 
event could cause affiliates to exhaust provisions quickly, without 
hope of restocking from ordinary suppliers.  HCA has therefore created 
the Central Supply Warehouse system, which is devoted to storing drugs 
and medical supplies vital to the national emergency response.  The 
Warehouse system requires each Division to set up a Central Supply 
Center ("CSC"), containing caches of burn/trauma kits, SARS/respiratory 
kits, and pharmaceutical kits.  The Far West and the East Florida 
Divisions are responsible for storing bio-isolation units.  
Additionally, HCA has developed the capacity to transport kits and 
bio-isolation units to any affiliate hospital within twenty-four 
hours.
HCA also recognizes that affiliates responding to catastrophic events 
may confront insufficient personnel to treat the number of incoming 
patients.  We therefore have relied on one of our subsidiaries, All 
About Staffing ("AAS"), to augment the emergency response capabilities 
of our affiliates.  Whenever an emergency occurs, AAS is ready to 
provide temporary staffing for affected facilities.  AAS generally 
provides nursing support, although an affected facility may request 
any type of staff essential to fulfilling patient needs.  HCA has 
appreciated the federal governmentï¿½s waiving of licensure requirements 
after declarations of emergency.  HCA believes that these waivers have 
enhanced our ability to draw upon staff throughout our network in 
response to emergencies of national dimensions.
So far, I have been speaking to you about how HCA has attempted to 
enhance network response to emergencies.  Now I would like to speak 
briefly about HCA efforts to prevent catastrophic events.  Throughout 
the HCA hospital network, we conduct syndromic surveillance of 
emergency room patients with laboratory testing needs.  For example, 
HCA monitors the white blood cell volume of such patients daily.  Our 
surveillance has been instrumental in identifying increased rates of 
influenza in the communities that our affiliates serve.  We believe 
that our syndromic surveillance system may be helpful in identifying 
the spread of other diseases of national import.  Currently, CDC is 
considering the role that HCA may play in national surveillance through 
the CDC Syndromic Surveillance Program.

III.	Strengthening the Emergency Preparedness of HCA Affiliates
HCA has taken steps to strengthen the emergency preparedness of our 
affiliates, as they inevitably are on the front-lines of catastrophic 
events.  As I mentioned previously, HCA requires affiliates to adopt 
the HEICS approach to crisis management.  There are two reasons for 
this requirement.  First, HEICS creates a common vocabulary for use 
during an emergency response.  HCA also has encouraged other healthcare 
providers to utilize HEICS, because we believe that more widespread use 
would ensure better coordination among first responders in every 
community.  Second, HEICS creates a framework of leadership positions, 
and assigns specific responsibilities to those positions.  The HEICS 
command structure establishes an "all hazards" command structure within 
the hospital, which links with the "community" command structure - 
whether that "community" comprises the neighborhoods in proximity to 
the hospital, our other HCA divisions, other local hospitals, or 
corporate offices.
HEICS therefore creates fully-operational chains of command at the 
first sign of an emergency.  Such command chains include the hospital 
experiencing the event, the Division and Market where that hospital is 
situated, the CSC associated with that Division, and HCA corporate 
headquarters.  Although HCA sister facilities are not direct links in 
the command chain, they stand ready to provide support, using HEICS as 
a shared platform.  As I mentioned previously, HEICS has the benefit of 
providing a common vocabulary, role definition, and organizational 
structure and accountability.  Accordingly, the system has the ability 
to supersede corporate titles and business positions that establish the 
traditional lines of authority during non-emergency situations.
As part of our Quality Review System ("QRS"), every 12-24 months HCA 
conducts routine audits and surveys of the emergency preparedness of 
each affiliate hospital.  While HCA data collection demonstrates that 
affiliates steadily are improving their programs, HCA continues to use 
QRS to ensure that facilities comply with the Disaster Readiness 
guidelines.

IV.	HCA Response to Hurricane Katrina
HCA has been in operation since 1968, and we often must contend with 
hurricanes and other natural disasters.  In 2004 alone, HCA affiliates 
in Florida were exposed to four major storms, including the devastating 
effects of Hurricanes Charley, Frances and Ivan.  Needless to say, 
severe weather preparedness is a top priority for our HCA affiliates 
in the Southeast.  Accordingly, in November of 2004, HCA senior 
executives and the CEOs of our affiliate hospitals met in Orlando, FL 
to discuss "Hurricane Lessons Learned."  The meeting helped HCA 
identify three areas in our severe weather plan that needed 
improvement:  (i) communications; (ii) transportation of supplies; and 
(iii) sourcing for alternative energy should public utilities fail.  
In the following months, HCA provided our affiliates with satellite 
phones, hurricane shutters, and additional portable emergency 
generators.  HCA also contracted with local businesses - like 
refrigeration companies, water companies, and diesel and gasoline 
retailers - to provide supplies quickly in the face of an emergency. 
In hurricane strike zones, we began to move food, medical supplies, 
and other gear to warehouses near hospitals.
Despite this extent of experience and preparation, Hurricane Katrina 
inflicted an unprecedented level of destruction on the region, which 
affected four HCA affiliates in Louisiana and Mississippi.  Lakeview 
Regional Medical Center in Covington, Louisiana sustained water and 
wind damage but remained open.  Garden Park Medical Center in 
Gulfport, Mississippi sustained flooding and roof damage, but resumed 
emergency room operation shortly after Hurricane Katrina passed.  
Since Garden Park Medical Center was one of only two hospitals still 
functioning in the Gulfport-Biloxi area after Hurricane Katrina, FEMA 
installed tents near its parking lot to give tetanus shots and to 
treat the less seriously injured.
HCA was forced to evacuate two facilities.  We closed Tulane-Lakeside 
Hospital in Metairie, Louisiana after local officials ordered a 
mandatory evacuation, and we transported patients, employees, and 
family members to a safe location by bus convoy.  Tulane University 
Hospital and Clinic ("TUHC") in New Orleans, Louisiana, which sustained 
the heaviest damage, mainly had to be evacuated by helicopter.  I would 
like to speak now of HCAï¿½s role in the TUHC evacuation and in the 
national emergency response to Hurricane Katrina.
On August 29, 2005, Hurricane Katrina made landfall in Louisiana as a 
Category 4 storm.  Shortly after Katrina passed, CEO Jim Montgomery 
reported that TUHC had suffered only minor damage and that flooding in 
New Orleans appeared to be limited.  Our relief was short-lived, 
however.  By the morning of August 30th, we became painfully aware of 
the true state of devastation caused by Hurricane Katrina.  HCA senior 
executives already had established a HEICS Command Center in the 
boardroom of the companyï¿½s headquarters in Nashville (the "Corporate 
Command Center"), and they remained there for the rest of the week to 
coordinate HCA disaster relief efforts along the Gulf Coast.
The Corporate Command Centerï¿½s top priority was to assist in the 
evacuation of TUHC in any way possible.  On the morning of August 30th, 
the TUHC Command Center reported that flooding had intensified in New 
Orleans and was threatening the hospitalï¿½s emergency generators.  At 
that point, TUHC housed approximately 180 patients, and one thousand 
staff members and their families.  Eleven patients were on ventilator 
support, and two were attached to heart pumps.  It was clear that TUHC 
had to be evacuated as soon as possible.  Although TUHC had called 
Acadian Ambulance to request helicopter assistance, we did not believe 
that Acadian alone could complete the evacuation within a reasonable 
period of time.  HCA therefore chartered twenty-four helicopters to 
support TUHC efforts.
On the morning of August 31st, the Corporate Command Center learned 
that HCA-chartered helicopters had arrived at TUHC, with HCA 
contractors providing flight coordination.  Since the TUHC evacuation 
proceeded in stages, HCA headquarters arranged to load each chartered 
helicopter with 750 pounds of food, water, and medical supplies to help 
TUHC staff and patients remaining in New Orleans.  Rather than 
transporting patients from one staging area to the next, the Corporate 
Command Center prearranged for other HCA facilities to be awaiting 
their reception.  Many of the evacuees initially were taken to Womenï¿½s 
and Childrenï¿½s Hospital in Lafayette, Louisiana.  HCA sent fifty nurses 
from AAS to support affiliated hospitals in the Gulf Coast receiving 
evacuees, and we stood ready to deploy 170 additional nurses, if 
needed.
On the evening of August 30th, TUHC lost backup power, causing its 
communications network to fail.  The following morning, headquarters 
helped TUHC set up a radio network by flying in three members of the 
Tallahassee Amateur Radio Club, who set up a portable generator-powered 
HAM radio with a satellite uplink.  The three radio operators used the 
satellite uplink to contact HCA offices in Tallahassee, FL for 
evacuation information.  They then used two-way radios to relay 
evacuation information to TUHC staff.  The three radio operators also 
delivered flight directions from HCA staff to the helicopter pilots.
On September 1st, TUHC completed the evacuation of its patients, along 
with thirty-eight patients from Charity Hospital.  The Corporate Command 
Center was encouraged by our hospitalï¿½s response to the greatest natural 
disaster in our nationï¿½s history.
Apart from my account of the evacuation itself, let me now give you a 
sense of the magnitude of HCAï¿½s response to Hurricane Katrina.  In terms 
of supplies, HCA provided the following to aid Katrinaï¿½s victims:
30,000 gallons of bottled water;
95,600 pounds of ice;
40,320 meals ready to eat (MREs);
five truckloads of other food;
four truckloads of linen;
one truckload of scrubs;
seven truckloads of assorted supplies;
one truckload of mattresses;
2,500 gallons of gasoline for vehicles and small portable generators; and
50,000 to 100,000 gallons of diesel fuel for large portable generators.
In terms of pharmaceuticals, HCA provided 17,360 doses of Cipro, tetanus 
immunizations, and insulin injections, along with other drugs.  To serve 
transportation needs, HCA provided twenty-four chartered helicopters for 
patient evacuation, as well as one fixed-wing plane to deliver supplies, 
two Boeing 727ï¿½s to transport staff and families to Houston and Atlanta, 
two hundred commercial airline tickets, fifty buses for evacuations, and 
one refrigeration truck.  In terms of communications, HCA provided cell 
phones and fifteen satellite phones.  Finally, HCA sponsored the Georgia-
based DMAT deployed in response to Hurricane Katrina.  That DMAT team 
traveled 1,400 miles to set up a mobile hospital in Galveston, TX and 
provided medical assistance to 4,000 evacuees, nearly all of whom were at 
least sixty-five years old.
HCAï¿½s efforts to help victims of Hurricane Katrina are continuing today. 
HCA established the "HCA Hope Fund" and contributed $4 million, also 
offering to match employee donations dollar-for-dollar.  HCAï¿½s hospital 
business partners and vendors - including the Rapides Foundation; 
St. Davidï¿½s Foundation; Health One; the Methodist Foundation; and 
Meditech - have contributed a total of $1.5 million.  HCA affiliates 
throughout the nation and our employees have donated an additional 
$450,000 to the Fund.  Displaced HCA employees continue to be on 
payroll, and HCA has offered to help them relocate - either temporarily 
or permanently - within the HCA network.  Moreover, the HCA Hope Fund 
gave $4.2 million in grants to help displaced employees meet immediate 
living expenses.  We also have donated $1 million to the American Red 
Cross.  Finally, HCA has shown its dedication to New Orleans by 
reopening Tulane-Lakeside Hospital, and by moving forward with the 
recovery process at TUHC.

V.	Lessons Learned From Hurricane Katrina
Since grappling with the effects of Hurricane Katrina last summer, HCA 
is continuing the process of analyzing our procedures for emergency 
preparation and response, continually seeking to enhance our practices 
and procedures.  For example, in March 2006, HCA headquarters will host 
a "Lessons Learned" meeting, which will be attended by each of our 
affiliate hospitals that experienced hurricanes and other natural 
disasters during 2005.  In the meantime, HCA is working with its 
affiliates to assess the positioning of emergency generators, and to 
enhance their communications capabilities.  In addition, our current 
efforts to improve upon disaster preparedness are focusing on 
mitigation, preparation, response and recovery for Avian Flu.
On balance though, I believe that the HCA response to Hurricane Katrina 
revealed far more strengths than weaknesses in our emergency 
preparedness strategy.  On the community level, HCA was able to relay 
critical information to TUHC and federal authorities after the 
hospitalï¿½s communications system failed.  Garden Park Medical Center in 
Gulfport, MS coordinated with FEMA to determine how to treat less 
seriously-injured victims of Katrina.  On the network level, HCA 
successfully created a command chain and drew upon the resources of all 
our affiliates to evacuate TUHC, to provide placement for all TUHC 
patients, and to provide food, water, and medical supplies as needed.  
On the affiliate level, TUHC followed the Disaster Readiness manual and 
developed an effective emergency preparedness plan.  At all levels, 
therefore, HCA launched an appropriate response to Hurricane Katrina.  
In sum, we are justly proud of our colleagues at TUHC, as well as all 
190,000 members of our staff, and the communities that we serve.
Thank you, Mr. Chairman and members of the Committee for your time and 
attention.  I will be happy to respond to any questions.

Mr. Whitfield.  Thank you, Mr. Lagarde.  At this time, I recognize 
Mr. James Montgomery for his five-minute statement.
Mr. Montgomery.  Good morning.  Iï¿½m Jim Montgomery, President and CEO 
of Tulane University Hospital and Clinic.  Tulane serves as a teaching 
hospital for Tulane University students and has formed a partnership 
between Tulane University and HCA.  Our three facilities provide New 
Orleans with a complete range of medical services.  As the committee 
is aware, Katrina inflicted heavy damage on Tulaneï¿½s main campus.  Yet 
we have made significant progress toward resuming our goal of bringing 
healthcare back to the community.  We anticipate reopening with limited 
services by the end of February.
Long before Katrina, Tulane had developed its own emergency and crisis 
management plans.  As President and CEO, I oversaw formulation of these 
plans and witnessed their implementation before, during, and after the 
aftermath of Katrina.  On Friday, August 26, we convened the formal 
Command Center meeting and evaluated staffing needs.  We also 
considered discharging patients and contacted the HCA Corporate Command 
Center in Nashville.  The following day, Katrina had been upgraded and 
we began to operate the Command Center on a 24-hour basis.  We asked 
staff to prepare for continuous 12-hour shifts and identified patients 
ready to be discharged.  We also contacted HCA and obtained an 
additional portable emergency generator.
Sunday, Katrina was upgraded to Category 5 and we continued the staff 
briefing.  In anticipation of flooding, we relocated an emergency 
generator to a higher floor.  We also moved food, water, and other 
medical supplies to a more secure location.  We improvised our plan by 
moving patients on life support to the fourth floor where we set up 
gas-powered generators, should the main generators fail.  At 3:00 a.m. 
Monday morning, Katrina made landfall.  We lost power, but the 
generators immediately began operating.  By late afternoon, the wind 
subsided, and based upon the immediate post-storm assessment, we 
moved the emergency department back to the first floor.  
Unfortunately, we soon learned that New Orleans was flooding.
Despite our best efforts, systemic failures caused disruption in our 
buildingï¿½s ability to maintain outside communications.
On Tuesday, when flooding disrupted our emergency generators, we 
decided to evacuate our patients.  Around 6:00 a.m., we contacted HCA 
to coordinate the helicopter evacuation.  By noon on Tuesday, 
helicopters began to evacuate our priority patients.  Command Center 
staff identified and secured receiving facilities for our evacuees.  
We also designated staff to accompany patients.
Into the night we evacuated patients, briefly halting flights upon 
reports of gunshots.  Later that afternoon we lost emergency power, 
but we had evacuated all ventilator patients and we immediately hooked 
up the heart pump patients to portable generators located on the fourth 
floor.  Shortly afterwards, we lost telephone communication.  On 
Wednesday, HCA-chartered helicopters arrived.  HCA also provided 
phones, food, and water.  After evacuating second and third priority 
patients, we stabilized the remaining patients based on helicopters and 
equipment that arrived.
In the afternoon, Charity Hospital requested that we evacuate four of 
their critical patients.  By Wednesday night, Tulane had evacuated 160 
patients in 36 hours and only 19 patients remained.  On Thursday, we 
evacuated all 19 remaining patients, including nonambulatory patients 
and heart patients, and a six-hundred pound bariatric patient.  Tulane 
evacuated those Charity Hospital patients who arrived that morning.  At 
all times, patient evacuation was our priority.  When arriving 
helicopters reached their capacity or were not configured to accommodate 
patients, we filled the space with staff and family members.  No space 
was wasted.
By Thursday night, 400 Tulane employees and family members remained. 
Tulane police secured the premises.  We slept in the parking garage.  By 
nightfall Friday, all patients were en route to Lafayette, Louisiana.
What would I do different?  First, we must address the placement of 
generators, and we agree on the need to focus on communication systems, 
making sure we are connected to colleagues and to police and fire 
rescue.  Lastly, no hospital can perform and function when there is a 
breakdown in civil order.
Mr. Chairman, Hurricane Katrina wrought unprecedented devastation on 
our community, but that experience, one that not one of us who 
struggled through it would wish to repeat, demonstrated the character 
of those who faced life-threatening challenges to help others at Tulane 
University, that included thousands of the employees and medical staff 
who banded together.  We achieved so much and will achieve much more.  
Thank you for your time and attention.  I will be happy to respond to 
your questions. 
[The prepared statement of James T. Montgomery follows:]
Prepared Statement of James T. Montgomery, President and Chief 
Executive Officer, Tulane University Hospital & Clinic, HCA Inc.

Summary

Tulane University Hospital and Clinic ("TUHC") serves as the teaching 
hospital for Tulane University Medical School, and operates as a 
partnership between Tulane University Medical Group and HCA, Inc. 
("HCA"). As the Committee undoubtedly is aware, Hurricane Katrina 
inflicted heavy damage on TUHCï¿½s main campus, which currently is 
closed. Although we are several months from restoring full operations, 
I have great confidence in HCAï¿½s ability to resume its presence 
serving healthcare needs in New Orleans, and we already have made 
significant progress toward that goal.
But long before Hurricane Katrina struck New Orleans, TUHC had 
developed its Emergency Preparedness Management Plan - a comprehensive 
document establishing operating procedures for emergency preparedness 
and crisis management (the "Plan"). Our Plan details both general 
emergency processes, as well as specific policies dealing with 
disasters, ranging from severe weather to biological and chemical 
terrorism. As President and Chief Executive Officer, I have overseen 
the formulation of that Plan. I also witnessed the Planï¿½s 
implementation - before, during, and in the aftermath of Hurricane 
Katrina.
Once activated due to a threatened emergency, the Plan may be divided 
into four distinct phases: (i) activating the chain of command; 
(ii) mobilizing emergency personnel; (iii) maintaining emergency 
equipment and supplies; and (iv) establishing communications with the 
appropriate authorities, both internal and outside the hospital. Being 
a part of the HCA network of healthcare providers, TUHC also has 
incorporated the Hospital Emergency Incident Command System ("HEICS") 
into our emergency planning. HEICS is a model utilized nationally by 
numerous industries and communities to establish an "all-hazards" 
command structure within the hospital (or other business), and it has 
helped HCA to activate a clear chain of command during an emergency.
Although Hurricane Katrina wrought unprecedented devastation on the 
New Orleans region, few accurately predicted the full force of 
destruction that would be left in its wake. But hurricane response is 
nothing new to TUHC, and HCA-affiliate hospitals nationwide have 
contended with natural disasters and emergencies of innumerable kinds. 
By relying on our established emergency preparedness and disaster 
management plans, TUHC was able to execute an evacuation of nearly two 
hundred patients, as well as over one thousand employees and families. 
And while Katrinaï¿½s scale and volatility forced us to improvise at 
times, and to rely on the larger HCA network to a greater extent than 
originally anticipated, in a word - our plans worked.

Mr. Chairman, members of the Committee and staff - good morning.  My 
name is Jim Montgomery, and I am the President and CEO of Tulane 
University Hospital and Clinic ("TUHC").  TUHC serves as the teaching 
hospital for Tulane University Medical School, and operates as a 
partnership between Tulane University Medical Group and HCA, Inc. 
("HCA").
TUHC comprises three facilities in the New Orleans metropolitan area.  
Our main campus is a 235-bed tertiary-care facility in downtown New 
Orleans.  Our secondary campus is the 119-bed Tulane-Lakeside Hospital 
in Metairie, LA ("Lakeside").  We also operate the DePaul Tulane 
Behavioral Health Center, a 110-bed psychiatric hospital located in
uptown New Orleans ("DePaul").  Among these three campuses, TUHC aims 
to provide a full range of medical services, including inpatient 
rehabilitation.
As the Committee undoubtedly is aware, Hurricane Katrina inflicted 
heavy damage on TUHCï¿½s main campus, and damage to Lakeside and DePaul 
sufficient to close each facility for a period of time.  The main 
downtown building currently is closed, and we are several months from 
the resumption of full operations.  Yet, I use the present tense to 
speak of HCAï¿½s presence in the New Orleans area, because I have great 
confidence in our rebuilding process.  In fact, we already have made 
significant progress toward that goal.  HCAï¿½s Lakeview Regional Medical 
Center, a separate HCA-operated facility located in Covington, Louisiana, 
never closed.  Lakeside resumed full operations within weeks of the 
storm.  At the main campus of TUHC, which suffered greatest damage, we 
have completed the remediation of safety and environmental hazards, and 
the Emergency Department has been renovated.  All told, our Tulane 
facilities have received over 14,000 patient visits since Hurricane 
Katrina unleashed its destruction last summer.  TUHC has achieved so 
much, and I have faith that we will achieve much more in the long 
months ahead.
As President and Chief Executive Officer, I have overseen the 
formulation of TUHCï¿½s policies and procedures for emergency 
preparedness management.  I also witnessed the Planï¿½s implementation - 
before, during, and in the aftermath of Hurricane Katrina.  I 
appreciate the opportunity to come before you this morning to discuss 
my experiences, both in terms of emergency preparedness and emergency 
management.

I.	TUHCï¿½s Emergency Preparedness Management Plan
Long before Hurricane Katrina struck New Orleans, TUHC had developed 
its Emergency Preparedness Management Plan - a comprehensive document 
establishing operating procedures for emergency preparedness and 
crisis management (the "Plan").  Our Plan details both general 
emergency processes, as well as specific policies dealing with 
disasters, ranging from severe weather to biological and chemical 
terrorism.  I would like to speak first about TUHCï¿½s general emergency 
plan, which may be divided into four distinct phases:  (i) activating 
the chain of command; (ii) mobilizing emergency personnel; 
(iii) maintaining emergency equipment and supplies; and 
(iv) establishing communications with the appropriate authorities, 
both internal and outside the hospital.

A.	Activating the Chain of Command
When faced with a threatened emergency, I am responsible for deciding 
whether to implement the Emergency Preparedness Management Plan.  In 
my absence, the Chief Operating Officer (COO), Kim Ryan, possesses the 
authority to make the decision.  Once the Plan is executed, our next 
step is to establish a local Command Center, comprised of nine 
individuals:  (i) the CEO and COO, who are responsible for overall 
coordination and decision-making; (ii) the Chief Medical Officer, Chief 
Nursing Officer, Clinic Representative, and Public Relations Officer, 
who are responsible for ensuring the continuity of medical operations at 
the main TUHC campus; and (iii) the Director of Facility Services, 
Hospital Safety Officer, and TUHC Police Director, who are responsible 
for protecting the physical integrity of TUHC buildings in downtown 
New Orleans.  In the event of an emergency, Lakeside, DePaul and the 
TUHC campuses each establish their own local Command Centers to monitor 
their respective preparedness and response.

B.	Mobilizing Emergency Personnel
The TUHC Command Center uses a coding system to alert in-house staff 
to emergencies.  For example, Code Orange means that either an internal 
or external disaster has occurred, and that TUHC immediately should 
implement the Emergency Preparedness Management Plan.  Code CD means 
that TUHC may experience civil disturbance, and that TUHC staff should 
execute the appropriate policies.  Typically, the TUHC Command Center 
announces these codes through the facility-wide speaker system.
Depending on the type and the severity of the emergency, the Command 
Center may summon off-duty staff to the hospital.  To enable the 
Command Center to reach such staff, the Plan requires that TUHC 
departments maintain a list of employee home and pager numbers.  Each 
department updates this call-in list on an annual basis.  The Plan 
also requires essential staff to contact their supervisors and await 
further instructions, even if they are off-duty and have learned of an
emergency through third-party sources, such as the media.

C.	Maintaining Emergency Equipment and Supplies
TUHCï¿½s Emergency Preparedness Management Plan anticipates that public 
utilities may fail during an emergency.  To ensure that critical areas 
and systems continue to operate, we have acquired stationary and 
portable emergency generators to ensure power, portable suction 
machines to provide vacuum, and portable cylinders to supply medical 
gases.  We have stockpiled potable water in bottles, and we can store 
non-potable water in containers, sinks, and tubs.  TUHC even has 
purchased bells for patients to call nurses in the event of a power 
disruption.  According to the Plan, departments responsible for medical 
care during an emergency create checklists of necessary medical 
supplies, and procure any that they find lacking.

D.	Communicating with Governmental Authorities and HCA
The Plan also provides for contingencies in the event that 
communication networks fail during an emergency.  If this occurs, our 
Command Center communicates with governmental authorities using the 
Hospital Emergency Area Radio ("HEAR") network.  And if HEAR fails, the 
Command Center may resort to use of our telecommunications system, 
which is connected to emergency generators in order to ensure back-up 
power.  TUHC police communicate using two-way radios, which are 
configured to ensure that they will not fail in the event of an 
emergency.
As I mentioned before, TUHC is part of the HCA network of healthcare 
providers.  Accordingly, like all HCA facilities, TUHC incorporated 
the Hospital Emergency Incident Command System ("HEICS") into our 
emergency planning.  HEICS is a model utilized nationally by numerous 
industries and communities to establish an "all-hazards" command 
structure within the hospital (or other business), and it has helped 
HCA to activate a clear chain of command during an emergency.  The 
use of HEICS as a common platform allows those engaged in a disaster to 
link communications with the command structure of multiple communities. 
Additionally, the structureï¿½s training and implementation results in 
multiple individualsï¿½ being prepared to assume an appropriate position 
within the command center.
For example, the role of commander within the command center during an 
emergency may be filled by the CEO or the COO, allowing both 
comparatively-trained individuals to serve on a rotating basis across 
an extended period of time.  HEICS also provides a common vocabulary to 
use when communicating with the corporate Command Center at HCA 
headquarters, as well as other affiliated hospitals, and the communities 
that we serve.  Both the command structure and the common vocabulary 
proved valuable in the wake of Hurricane Katrina, when TUHC turned to 
HCAï¿½s Corporate Disaster Team ("CDT") and other HCA hospital and 
organizational staff for support in navigating the unimaginable 
devastation.

II.	TUHCï¿½s Severe Weather Program and Total Facility Evacuation 
Plan
Before relating my experiences with Hurricane Katrina, I would like 
briefly to describe TUHCï¿½s Severe Weather Program (the "Program"), 
which outlines specific policies to deal with adverse weather 
conditions.  Given our location in downtown New Orleans, hurricanes 
obviously have been our primary concern.  With respect to hurricane 
preparedness, our Program is divided into six stages for disaster 
mitigation.
The First Stage extends from December 1st to May 31st, which falls 
outside the Gulf Coastï¿½s official hurricane season.  During this stage, 
TUHC operates normally, while our Hospital Safety Officer updates the 
Program and educates employees on compliance with its procedures.
The Second Stage of the Program extends from June 1st to November 30th, 
which officially comprises hurricane season in the Gulf Coast.  During 
this stage, all TUHC departments are required to review the Program and 
designate "essential" personnel.  In addition, they update employee 
call-in lists, distributing copies to the Hospital Safety Officer and 
the hospital operators.  All departments also are required to inventory 
and confirm the quality of necessary emergency supplies.
When the National Weather Serviceï¿½s National Hurricane Center issues a 
hurricane advisory, we initiate the Third Stage of our Program.  During 
this stage, our COO announces the implementation of the Programï¿½s 
emergency measures.  Essential staff and other off-duty personnel 
remain on standby, and departments are required to complete their 
supply inventories and arrange for additional deliveries as needed. 
All departments maintain close contact with the hospital operations 
personnel.
When the National Hurricane Center issues a hurricane watch, we 
initiate the Fourth Stage of our Program.  During this stage, the COO 
establishes the local Command Center.  Depending on the specific 
circumstances, the Medical Director may decide to summon off-duty 
physicians to TUHC.  In addition, the Pharmacy Department and Emergency 
Department are required to inventory supplies of typhoid vaccine, 
insulin, and snakebite antidotes, and report their results to the 
Command Center.
When the National Hurricane Center issues a hurricane warning, we 
initiate the Fifth Stage of our Program.  During this stage, the 
Command Center takes complete control of TUHC operations.  To ensure 
that TUHC has sufficient beds should mass casualties result from the 
hurricane, the Command Center cancels all scheduled elective surgery 
and discharges appropriate patients.  It also must verify that all 
departments have completed preparations for the arrival of the 
hurricane, including the procurement of supplies, and confirm that 
the HEAR radio is adequately staffed and operational.  The Command 
Center is responsible for ensuring that sufficient staffing is 
available for at least two continuous, twelve-hour shifts, as well 
as establishing a pool of personnel not assigned to particular 
departments, who can fulfill different responsibilities if necessary.
During the Fifth Stage, nursing staff move remaining patients to 
interior rooms, which are less prone to wind damage.  They would then 
close drapes and blinds throughout TUHC, and verify that flashlights 
and fresh batteries are available.  Finally, nursing staff fill 
bathtubs, whirlpools, and other vessels with non-potable water.
The Sixth Stage of our Severe Weather Program takes place 
immediately after the hurricane.  The Command Center must make sure 
that the communications network still is operational, and then uses 
the network to fulfill internal and external requests for services 
and supplies.  Assuming that TUHC remains relatively intact, the 
Command Center may prepare personnel to receive mass casualties.  If 
TUHC has suffered significant structural damage - as was the case 
following Hurricane Katrina - then the Command Center implements the 
Total Facility Evacuation Plan.  In general, TUHC prioritizes 
patients for evacuation in the following way:  (i) patients in 
imminent danger from the disaster; (ii) wheelchair and ambulatory 
patients; (iii) bed-ridden patients; and (iv) patients receiving 
oxygen.  Please note, Mr. Chairman, that this system of 
classification and priority assumes that TUHC emergency generators 
are in operation and powering ventilators.
Upon notification of total evacuation, triage physicians and 
nurses are required to screen patients, placing them in one of the 
above four categories, and then immediately provide a list of patient 
classifications to the Command Center and the Nursing Supervisor.  
Prior to Katrina, the Total Facility Evacuation Plan anticipated that 
most patients would be transported by commercially-owned buses.  If 
bus transportation is not feasible, the Plan authorizes TUHC to 
transport patients using any means available, including vehicles 
provided by the National Guard, the City of New Orleans, or a state 
agency.  After the Total Facility Evacuation Plan has been completed, 
nurses or other hospital staff search each room to ensure that no 
patients, visitors, or employees remain in the building.

III.	TUHCï¿½s Response to Hurricane Katrina
Although Hurricane Katrina wrought unprecedented devastation on the 
New Orleans region, few accurately predicted the full force of 
destruction that would be left in its wake.  But hurricane response is 
nothing new to TUHC, and HCA-affiliate hospitals nationwide have 
contended with natural disasters and emergencies of innumerable kinds. 
By relying on our Emergency Preparedness Management Plan, Severe 
Weather Program, and Total Facility Evacuation Plan, TUHC was able to 
execute an evacuation of nearly two hundred patients, as well as over 
one thousand employees and families.  Although Katrinaï¿½s scale and 
volatility forced us to improvise at times, and to rely on the larger 
HCA network to a greater extent than originally anticipated, in a 
word - our plans worked.
I would like to conclude my testimony by giving you a day-by-day 
account of the TUHC downtown campus response to Hurricane Katrina.  I 
then hope to discuss both where the plan worked, and where human 
ingenuity had to take over.
By Friday, August 26, 2005, Hurricane Katrina had formed as a 
Category 1 storm moving westward towards Mobile, Alabama.  At that 
time, the National Hurricane Center was predicting that Katrina would 
strengthen and likely change course, with New Orleans falling within 
the potential landfall forecasts.  As a precautionary measure, TUHC 
implemented the Fourth Stage of our Severe Weather Program. 
Accordingly, COO Kim Ryan convened the first formal Command Center 
meeting, and we considered TUHCï¿½s staffing needs during the hurricane.  
We also discussed whether TUHC should begin discharging patients.  We 
also contacted the Corporate Command Center at HCA headquarters in 
Nashville to discuss the status of Hurricane Katrina and TUHCï¿½s 
anticipated needs.  At the end of that day, we adjourned the TUHC 
Command Center meeting, agreeing to meet again at noon the next day.  
All told, we had followed the Severe Weather Program to the letter.
On Saturday, August 27, 2005, the National Hurricane Center upgraded 
Hurricane Katrina to a Category 3 storm and calculated that the eye 
would pass over Alabama or Mississippi.  Given our continued proximity 
to the predicted storm track when we reconvened the Command Center at 
noon, we initiated the Fifth Stage of the Program.  At this point, we 
began to operate the Command Center on a 24-hour basis, and began to 
make provisions at the hospital for sheltering employees and families. 
We determined which employees would be asked to staff each of two 
continuous, twelve-hour shifts, and the Chief Medical Officer requested 
that physicians identify patients ready to be discharged.  We also 
contacted HCA headquarters and obtained an additional portable 
emergency generator.  By the end of the day, we had completed about 
half of the duties mandated by the Fifth Stage of the Program.
On Sunday, August 28, 2005, the National Hurricane Center upgraded 
Hurricane Katrina to a Category 5 storm and refined its landfall 
prediction to the border between Louisiana and Mississippi.  We 
continued Fifth Stage preparations.  TUHC physicians and staff 
arrived at 6:30 a.m., according to Plan, and the Command Center 
conducted a staff briefing on emergency procedures prior to the start 
of each shift.  In anticipation of possible flooding, we relocated 
the Emergency Department and the Central Sterile Supply unit to the 
3rd floor of the building.  We also moved food, water, and other 
medical supplies to a more secure location on the 5th floor.  TUHC 
staff identified the number of patients on life support - at that point,
we had eleven ventilator patients, none using oscillators, and two 
patients dependent on heart pumps (BVAD).  We made our first 
improvisation from the Plans by moving patients on life support to the 
4th floor, where we set up gas-powered portable generators.  Should our 
main emergency generators fail, we wanted the ability to connect the 
patients to portable generators as rapidly as possible.  We even were 
prepared to feed the portable generators with gasoline from our cars, 
if necessary.
Late on Sunday afternoon, government officials requested that we 
provide space for fifty-eight hurricane victims with special needs, 
who were housed at the Superdome.  A significant number required 
oxygen or otherwise were medically fragile, potentially placing them 
at risk in the event of structural damage to the facility.  
Nevertheless, we agreed to house them at TUHC.  These individuals also
were expected to arrive accompanied by a federal Disaster Medical 
Assistance Team (DMAT), able to provide any necessary medical care and 
additional supplies.  However, the DMAT encountered delays at Baton 
Rouge, so we immediately assembled a group of Internal Medicine 
physicians to assess their medical condition.
At roughly 3:00 a.m. on Monday, August 29, 2005, Hurricane Katrina made 
landfall in Louisiana as a Category 4 storm, with hurricane-force winds 
battering the hospital.  We lost power at about 6:00 a.m., but the 
emergency generators immediately began operating.  By around noon, the 
winds began to subside, so TUHC staff inspected the outside of the 
downtown building.  We found only minor roof damage and a few broken 
windows.  Better yet, it appeared that the flooding was limited.  Based 
upon the immediate post-storm assessment, and in order to maximize the 
facilityï¿½s patient-care resources, the Command Center decided to move 
the Emergency Department back to the 1st floor, and as required by the 
Sixth Stage of the Severe Weather Program, we prepared for the arrival 
of hurricane casualties.
Unfortunately, our jubilation on Monday afternoon was short-lived.  By 
9:30 p.m., the Director of Facility Services notified the TUHC Command 
Center that New Orleans was flooding at a rate of one inch every ten to 
fifteen minutes.  By midnight, we realized that we had no idea when - 
or if - the flooding would stop.  And despite our best planning 
efforts, systemic failures of the regional and national communications 
systems caused significant disruptions in our ability to maintain 
communications with outside individuals and entities.  Without the 
means to obtain reliable current information, the Command Center 
decided to return the Emergency Department to the 3rd floor, along with 
the Central Sterile Supply, Pharmacy, and Materials Management units.
On Tuesday, August 30, 2005, the Command Center discovered that the 
flooding threatened our emergency generators.  In fact, notwithstanding 
the prospect of flood damage, we had depended on the generators since 
Monday and projected that they would provide at best another two to 
three hours of emergency power.  At that point, I decided that we must 
evacuate our most critically-ill patients.  At around 3:00 a.m., we 
contacted HCA headquarters and Acadian Ambulance in order to coordinate 
a helicopter evacuation.  Since the designated area at TUHC for helipad 
services had flooded, the Command Center decided to employ the roof of 
the Saratoga Parking Garage as the best alternative helicopter landing 
site.  Personnel from the TUHC Facilities Department prepared the roof 
by removing four light poles.
Once the decision was reached to initiate a total facility evacuation, 
the Command Center asked the Chief Medical Officer and her staff to
assign evacuation priorities to all remaining patients, without 
distinguishing between TUHC patients and those from the Superdome.  
First, we evacuated the neonates and the patients in our Pediatric 
Intensive Care Unit on ventilator support.  We then determined that 
patients on ventilator support would be most vulnerable should 
emergency generators fail.  Accordingly, we deviated from the 
priorities established by the Total Facility Evacuation Plan, 
evacuating the adults on ventilator support next.  The third group to 
be evacuated would be the remaining critical care patients, except for 
the two patients on heart pumps (BVAD).  They were to be followed by 
the pediatric and adult patients needing urgent medical or surgical
care.  The final evacuation group was to include all remaining patients. 
After determining the evacuation priority, we then tried to locate 
ambulatory pumps and helicopters with high weight limits, since two 
patients were connected to heart pumps weighing over 500 pounds.
At noon on Tuesday, we began the helicopter evacuation of our first 
priority patients.  The Command Center staff, coordinating with HCA 
headquarters, identified and secured receiving facilities for our 
evacuees.  The Command Center also determined which staff members needed 
to accompany patients during the evacuation.  All afternoon and well 
into the night, we continually evacuated patients, briefly halting 
flights only when the Command Center received reports of gunshots.
We lost emergency generator power between 5:30 and 6:00 p.m.  Thankfully, 
by then we already had evacuated all of the ventilator patients, and we 
immediately hooked up the two heart pump patients to the portable 
generators located on the 4th floor.  At around 7:00 p.m., we lost all 
reliable telephone communication.  We then decided to split the Command
Center into two functioning organizations.  The Clinical Care Command 
Center relocated to the Deming Pavilion, which was powered by a portable 
generator.  The Administrative Command Center relocated to the Lab 
Conference Room, enabling communications through incoming calls on the 
hospitalï¿½s "brown phones" - analog telephones that are hard-wired to 
BellSouth, not routed through the TUHC digital switch.  The two Command 
Centers were able to communicate with each other, and with the roof of
the Saratoga Parking Garage, through two-way radios.  Neither Command 
Center had a dependable means to make outgoing local or long-distance 
calls, however, so we were forced to rely on sporadic mobile phone and 
Blackberry service, as well as calling cards on pay phones.
On Wednesday, August 31, 2005, the HCA-chartered helicopters arrived to 
supplement the evacuation process.  HCA headquarters also provided 
satellite phones, food, water, medical supplies, and bulletproof vests.  
After TUHC evacuated all second and third priority patients, we started
taking into account the configuration of the helicopters to determine 
further evacuation priority.  For example, if the helicopter was 
configured for stretchers, we would evacuate patients on stretchers.  
If the helicopter was configured with seats, we would evacuate 
ambulatory patients.  At some point during the morning, the Louisiana 
Department of Wildlife and Fisheries arrived with boats to assist with
the evacuation of ambulatory Superdome patients and their families.  
In the afternoon, we received a request from Charity Hospital and 
evacuated four of their critically-ill patients, each of whom had 
already been hand-ventilated for two days.  By the end of the day on 
Wednesday, TUHC had evacuated around 160 patients in thirty-six hours.  
Only nineteen patients remained, including a bariatric patient weighing 
over six-hundred pounds, and a cardiac patient connected to a 500-pound 
heart pump.
On Thursday, September 1, 2005, we evacuated the nineteen remaining 
TUHC patients.  This group included non-ambulatory patients, who our 
staff carried flight after flight, down darkened stairwells in 
oppressive heat.  Two remaining evacuees posed particular logistical 
challenges - a heart-pump patient, whose survival depended upon more 
than five hundred pounds of medical equipment, and the 600-pound 
bariatric patient.  In addition, TUHC evacuated dozens of additional 
patients who were transported that morning from Charity Hospital.  At 
all times, patient evacuation was our priority.  When arriving 
helicopters reached their capacity for additional patients, or were not 
configured to accommodate patient transport, we filled any available 
space with hospital staff and family members.  No space was wasted.  
Helicopters took staff to an airport staging area, where they were 
decontaminated and placed on buses headed for Lafayette, LA.  At the 
end of Thursday, about four hundred TUHC employees and family members 
still awaited evacuation.  At the suggestion of TUHC police, we all 
slept in the Saratoga Parking Garage, making it easier to secure the 
premises.  By nightfall on Friday, all TUHC employees were en route to 
Lafayette, LA.
Thank you, Mr. Chairman and members of the Committee for your time and 
attention.  I will be happy to respond to any questions.

Mr. Whitfield.  Thank you, Mr. Montgomery.  At this time, we recognize 
Mr. Rene Goux, who is the Chief Executive Officer of Memorial Medical 
Hospital for his five minutes.
Mr. Goux.  Thank you.  My name is Rene Goux, Iï¿½m the CEO of Memorial 
Medical Center in New Orleans, Louisiana.  I was at Memorial before, 
during, and after the hurricane ripped through the city.  As a person 
who was commanding Memorialï¿½s operations during this tragedy, I would 
like to speak about Memorialï¿½s preparedness and response efforts.
I have been involved with hospital management in Louisiana for 27 years, 
including two at Memorial.  As we know now, the scope of Katrinaï¿½s 
devastation is unprecedented both on a broader scale and on its impact 
on the infrastructure of healthcare in New Orleans.  Although we made 
it through the hurricane, the failure of the cityï¿½s levees on a massive 
and unexpected scale overwhelmed emergency power systems.  Surrounded by 
10 feet of polluted oil-slick water without power or reliable 
communications, the staff at Memorial worked for nearly five days to 
treat, feed, and evacuate patients, families, and local residents who 
sheltered in the hospital.
The weekend before Katrina reached land on Monday, August 29, we 
implemented our standard emergency preparedness procedures.  These 
included establishing an incident command center, canceling elective 
surgical procedures and releasing ambulatory patients, and stocking a 
four-day supply of food, fuel, and other provisions.
On Sunday, August 28, at 9:30 a.m., the mayor issued a citywide 
evacuation order, but that order did not call for the evacuation of 
hospitals.  During the hurricane, we could feel the entire building 
shaking violently in the wind.  Windows in the walkways that connect 
the medical office buildings to the hospital began breaking as debris 
flew through the city streets.  When daylight came after the storm, we 
could see about a foot of water in the street and a lot of wind damage 
to the surrounding area, with many trees down.  The power had gone out, 
but we were able to convert to generators.  We believed we had survived 
the hurricane, and things could get back to normal quickly.
Then, on Tuesday morning, the levees started breaking, and the water 
began rising rapidly, ten to 12 feet until our basement was completely 
flooded.  We were able to move patients, food, and other supplies to 
the higher floors.  As the water continued to rise, we were completely 
cut off.  I immediately moved the Command Center to the third floor 
and worked with the hospital management to reassess and respond to the 
evolving situation.  By Tuesday evening, when we were able to evacuate 
18 babies from a neonatal intensive care unit aboard Coast Guard 
helicopters, spirits were lifted, as we saw this as evidence that 
rescue operations were underway.
Throughout Tuesday and into Wednesday, as we watched from the windows 
and roofs, the focus shifted to the thousands of residents trapped in 
attics and rooftops through the flood zones.
Conditions at the hospital deteriorated rapidly.  The hospitalï¿½s air 
conditioning system broke down, causing temperatures to reach higher 
than 105 degrees.  We started losing electricity on Tuesday and we had 
no power for the last two days.  There was no plumbing and the toilets 
were overflowing.  The smell of sewerage was unbearable.  We started 
breaking windows to give ventilation.  Communication with Tenet 
headquarters was unreliable and nearly nonexistent with emergency 
officials.
Personal safety become a huge issue as local residents swam to the 
parking garage seeking a dry area.  At times, the sound of gunfire rang 
throughout the streets.  Looting broke out throughout the neighborhood. 
We locked down the hospital and ensured that no outsiders could get 
inside, and established a perimeter around the hospital.  On Wednesday, 
officials at Tenet were informed by government officials that if they 
wanted their hospitals, including Memorial, evacuated, they would have 
to mount a private rescue effort.  None of the elevators were working, 
so we had to carry patients up stairwells to helipads or down to boats, 
some as many as eight flights.  When the handheld radios gave out, we 
stationed people on every floor in the parking garage to transmit 
messages in furtherance of our internal evacuation efforts.  We 
completed our evacuation by Thursday evening.  At the end, about 70 of 
us spent the night on the rooftop waiting for the helicopters to 
return in the morning.
Again, our mission is compassionate healthcare.  Throughout this ordeal, 
our staff at Memorial and our colleagues in Dallas never forgot this. 
Our well-trained professionals put the safety, comfort, and well-being 
of our patients first.  I want to take this opportunity to recognize 
the staff of Memorialï¿½s resilience, courage, and dedication in the face
of one of the Nationï¿½s greatest natural disasters.  In the weeks and
months after the hurricane, it has become clear just how long and 
difficult the road to recovery will be.  I am pleased that in October,
Tenet announced the companyï¿½s commitment to remain in New Orleans, 
joining our remaining hospitals in a locally managed network aided by 
our downtown campus.
Let me reiterate:  First, at Memorial we felt prepared for even a major
hurricane like Katrina.  What we could not be ready for is a flood 
caused by the failure of levees and a municipal public system that 
closed all the other nearby hospitals and stranded all of us inside
Memorial without municipal power, water, and sanitation for four days. 
When that catastrophe happened, Iï¿½m proud to say we counted on the
heroism of our people to get us through.  Thank you for the opportunity
to address the subcommittee. 
[The prepared statement of Rene Goux follows:]
Prepared Statement of Rene Goux, Chief Executive Officer, Memorial 
Hospital, Tenet Healthcare Corporation

Summary

As CEO of Tenetï¿½s Memorial Medical Center in New Orleans, Louisiana, I 
led Memorialï¿½s ground floor preparation and response efforts related to 
Hurricane Katrina.
Despite unprecedented devastation caused by Hurricane Katrina, including 
the failure of the cityï¿½s levees, which overwhelmed emergency response 
systems, staff at Memorial worked tirelessly to treat, feed and evacuate 
patients and others who sought shelter at the hospital.
Before the storm hit, we set up an Incident Command Center at Memorial,
ensured that we had a four-day supply of food, fuel and other provisions,
canceled elective procedures and released ambulatory patients.  We also 
followed Mayor Naginï¿½s evacuation order, which did not call for the 
evacuation of hospitals and first-responders.
During the storm, we lost power but were able to rely on our generators. 
Initially, we believed we had survived the hurricane and that the 
situation would return to normal fairly quickly.
However, the levees failed and the situation began to deteriorate 
rapidly, causing serious flooding.  We moved patients, food, supplies, 
and the Incident Command Center to higher floors.  Our chief priority
became the safe evacuation of our patients, and by Tuesday evening, we 
had safely evacuated 18 babies from our neonatal intensive-care unit 
aboard Coast Guard helicopters.
By Wednesday morning, flooding had caused a total loss of electrical 
power.  There was no plumbing; the toilets were overflowing; and the 
smell of sewage was nauseating.  We broke windows to create ventilation 
for our patients.  With no working elevators, we carried patients up 
stairwells to the helipad or down to the boats - some as many as eight 
flights.
Communication with Dallas was difficult, as cell phones and a satellite 
phone had service only sporadically; communication with emergency 
officials was nearly non-existent.
When looting and the sound of gunfire threatened our personal safety, 
we locked-down the hospital, established a perimeter around the hospital,
and required everyone inside to wear their identification wristbands.
Despite planning, training and preparing for a major hurricane like 
Katrina, we could not be ready for the catastrophic flooding caused by 
the failure of the levees and the municipal pumping system, which 
stranded us without power, water and sanitation for four days.
Under the dire circumstances, our well-trained professionals put the 
safety, comfort and well-being of our patients first.  Additionally, we 
followed established procedures and were able to safely evacuate all 
patients and family members by Thursday evening.

Chairman Whitfield, Congressman Stupak, Subcommittee members:
I thank you for inviting me to appear today before the Subcommittee.
I am the CEO of Memorial Medical Center in New Orleans, Louisiana. 
Memorial is a 347 bed tertiary care hospital located on Napoleon Avenue 
in the Freret neighborhood of downtown New Orleans.  The hospital was 
opened in 1926 and is still known to many of the cityï¿½s inhabitants by 
its original name - Southern Baptist Hospital.  The hospital grounds 
consist of eight buildings, covering three blocks, and include the 
general hospital, the New Orleans Cancer Institute, the New Orleans 
Surgery and Heart Institute, a Diabetes Management Center and Sleep 
Disorders Center, and a medical office building for more than 100 
physicians.  In addition, Memorial provides residency training for 
physicians in conjunction with the Louisiana State University Health 
Sciences Center.
I was at Memorial before, during, and after Hurricane Katrina ripped 
through the city.  As the person who was commanding Memorialï¿½s 
operations during this tragedy, I would like to speak about Memorialï¿½s 
preparedness and response efforts.
I am joined today by Bob Smith, the Senior Vice President of Operations 
for the Texas/Gulf Coast Region of Tenet Healthcare, who will speak 
about the impact of Katrina throughout the six Tenet hospitals located
in New Orleans and Mississippi - including Lindy Boggs Medical Center 
in Orleans Parish; Kenner Regional Medical Center and Meadowcrest
Hospital in Jefferson Parish; NorthShore Regional Medical Center in 
Slidell, Louisiana; and Gulf Coast Medical Center in Biloxi, 
Mississippi.
I have been involved in hospital management in Louisiana for 27 years, 
including two years at Memorial Medical Center.  As we all now know, the 
scope of Katrinaï¿½s devastation is unprecedented on a broader scale, and 
the same is true of its impact on the health care infrastructure of 
New Orleans.  Although we made it through the hurricane, the failure of 
the cityï¿½s levees on a massive and unexpected scale overwhelmed
emergency response systems at the local, state and - ultimately - 
federal levels.  Surrounded by ten feet of polluted, oil slicked 
water, without power or reliable communications, the staff of Memorial 
worked for nearly five days to treat, feed and evacuate patients, 
families and local residents who sought shelter at the hospital.  I 
will never forget the valiant efforts of those people and the hundreds 
of others involved in the rescue.
The weekend before Katrina reached land on Monday, August 29th, we 
implemented our standard hurricane preparedness procedures.  These 
procedures are outlined in Memorialï¿½s Hurricane Preparedness Plan, a 
copy of which has been provided to the Subcommittee.  The plan was 
developed in coordination with local and state emergency response 
officials, and was available for review by state and local emergency 
planning organizations, as required by Louisiana hospital licensing 
regulations.
These procedures included: (1) establishing an Incident Command Center, 
which we initially set up on Memorialï¿½s first floor administrative 
offices; (2) canceling elective procedures and releasing any ambulatory 
patients; and (3) stocking a four-day supply of food, fuel and other 
provisions.  On Sunday, August 28th at 9:30 AM, Mayor Nagin issued a 
city-wide evacuation order, but that order did not call for the 
evacuation of hospitals and first-responders.  This was understandable,
as many patients in acute care hospitals are too sick to move,
especially on a long trip by ground or ambulance, to a facility far 
enough away as to be outside the broad and unpredictable path of a 
major storm such as Katrina.  Moreover, hospitals are a critical part 
of the local emergency response system that is needed for post-storm
rescue and recovery.
We had approximately 2,000 people at Memorial during Katrina--260 
patients, 500 employees and hundreds of family members who had come 
to the hospital to ride out the storm.  During the hurricane, we could
feel the whole building shaking violently in the wind.  Windows in the 
walkways that connect the medical office building to the hospital began
breaking out as debris flew through city streets.  It was quite an 
experience.  When daylight came after the storm, we could see about a 
foot of water in the street and a lot of wind damage to the 
surrounding area, with many trees down.  The power had gone out, but
we were able to convert to our generators.  We believed we had 
survived the hurricane and things would get back to normal fairly 
quickly.  In fact, some people left the hospital to survey damage 
throughout the city and check their own homes.
Then, on Tuesday morning, the levees started breaking.  Our hospital 
sits in the New Orleans "bowl."  The water started rising rapidly, 
10 or 12 feet, until our basement was completely flooded.  It was 
terrifying to see it rise so quickly.  We didnï¿½t know where it was 
going to stop.  We were able to move patients, food and other supplies 
up to the higher floors.  As the water continued to rise, we were 
completely cut off.  I immediately moved the Incident Command Center 
to the third floor and worked with the hospital management leaders to 
reassess and respond to the evolving situation.
By Tuesday evening, we were able to evacuate 18 babies from our 
neonatal intensive-care unit aboard Coast Guard helicopters.  Spirits 
were lifted, as we saw this as evidence that rescue operations were 
underway.  But throughout Tuesday night and into Wednesday, as we 
watched from windows and the roof, the focus shifted to the thousands 
of residents trapped in attics and on rooftops throughout the flood 
zone.
Conditions at the hospital deteriorated rapidly.  The hospitalï¿½s 
air-conditioning system broke down, causing temperatures to reach 
higher than 105 degrees.  We started losing electrical systems on 
Tuesday, and we had no municipal electrical power for the last two 
days.  There was no plumbing; the toilets were overflowing.  The 
smell of sewage was nauseating and it was unbearably hot.  We started 
breaking windows to give our patients some ventilation.  Communications
were unreliable, although we were able to maintain sporadic contact 
with Tenet headquarters by cell phone and a satellite phone delivered 
by helicopter.  Communication with emergency officials was nearly 
nonexistent.
Personal safety became a huge issue as local residents swam into the 
parking garage seeking a dry area.  At times, the sound of gunfire rang 
out through the streets.  Looting broke out throughout the 
neighborhood.  We locked-down the hospital to ensure that no outsiders 
could get inside and established a perimeter around the hospital.  We 
also required that everyone legitimately within the hospital wear 
their identification wristbands.
On Wednesday morning, some guys--volunteers from southern Louisiana--
showed up in airboats.  There was no sign of any organized rescue 
effort, just these kind people who came from out of nowhere.  We were 
able to get some non-critical patients and family members out with 
them - although we later learned that many of these people were only 
taken as far as the Superdome or other dry land, joining the thousands 
of others trapped in the devastated city.
On Wednesday, officials at Tenet were informed by government officials 
that if they wanted their hospitals - including Memorial - evacuated, 
they would have to mount a private rescue effort.  Bob Smith will speak 
about that effort in more detail.  At Memorial, we had a core group of 
nurses and about 40 physicians who were just incredible - working 
around the clock to treat patients and prepare them for evacuation.  
Many of their family members - including teenagers and young kids - 
stood for hour upon hour upon hour fanning our patients by hand and 
bathing them with bottled water to make them more comfortable.
None of the elevators were working, so we had to carry patients up 
stairwells to the helipad or down to the boats - some as many as 
eight flights.  When our hand-held radios gave out, we stationed
people on every floor and in the parking garage to transmit messages
in furtherance of our internal evacuation efforts.
We completed our evacuation of patients and family members by Thursday 
evening.  At the end, about 70 of us spent the night on the rooftop 
waiting for the helicopters to return in the morning.  At some point, 
there was a huge explosion in the city.  We could see looters in some
of the buildings nearby, and continued to hear gunshots in other 
parts of the city.
Again, our mission is compassionate healthcare.  Throughout this 
incredible ordeal, the staff at Memorial and our colleagues in Dallas 
never forgot this.  Our well-trained professionals put the safety, 
comfort, and well-being of our patients first.  I want to take this 
opportunity to recognize publicly their resilience, courage, and 
dedication, in the face of one of this nationï¿½s greatest national 
disasters.  Their actions are even more heroic when you consider that
many of these people lost their homes to Katrina and left the hospital 
only to themselves enter the stream of evacuees facing an uncertain 
future.  I am pleased that Bob is here to talk to you about the 
extensive efforts Tenet has made to assist our displaced employees.
In the weeks and months after the hurricane, I have remained in New 
Orleans working with the management teams of Tenetï¿½s four other 
Louisiana hospitals and corporate management on the recovery.  During
this time, it has become clear just how long and difficult the road 
back will be, especially for Orleans Parish.  With the loss of six 
major downtown hospitals, the health care infrastructure of the 
parish was nearly destroyed.  And as many have observed, we face a 
classic "chicken-and-egg" problem - hospitals and other healthcare 
facilities canï¿½t survive without a population to support them, but 
people are hesitant to return to a city where health services are not 
readily available.  I am pleased that in October, Tenet announced the
companyï¿½s commitment to remain in New Orleans, joining our remaining 
hospitals into a locally managed network anchored by a downtown 
campus.  In doing so, we will be working with government officials, 
private organizations, and community representatives to ensure that 
residents of New Orleans will have access to the highest quality 
care available.
Let me reiterate a couple of points that Iï¿½m sure this committee is 
most interested in.  First, at Memorial we felt prepared for even a 
major hurricane like Katrina.  We planned for it and trained for it,
and the hospital and staff had been through numerous storms before.  
What we couldnï¿½t be ready for was a flood coupled with the failure of 
the levees and municipal pumping system that closed all the other 
nearby hospitals and stranded all of us inside Memorial without
municipal power, water and sanitation for four days.  When that 
catastrophe happened, Iï¿½m proud to say that we could count on the 
heroism of our people to get us through.
Thank you again for the opportunity to address the Subcommittee 
today.

Mr. Whitfield.  Thank you, Mr. Goux.  At this time, we recognize 
Mr. Robert Smith, also with Tenet.
Mr. Smith.  Thank you, Mr. Chairman.  I am Bob Smith, Senior Vice 
President of Operations for Tenet Gulf, which includes New Orleans, 
Louisiana, and Biloxi, Mississippi.  My office is in Dallas, where I 
oversaw the relief efforts for our six hospitals in two affected areas, 
so mine was the prospective of an outsider trying to deal with the 
crisis.  These efforts began as the focus on the logistics of supplies, 
food, medicine, water, and fuel and rapidly evolved into an evacuation 
that ultimately included five of our six hospitals, and those of others 
as well.
Our North Region Medical Center in Slidell, Louisiana, remained in 
operation to support the needs of the community and acted oftentimes as
a field hospital, receiving patients from all over the region during 
that time frame.  While we worked with the resources from all levels of 
government, we were just simply overwhelmed.  Everyone tried to help, 
but the magnitude of the situation simply overpowered them all.
So, what have we learned?  Each of you has really articulated very well 
this morning other comments I was going to make about the things that 
you have seen and what happens, so let me be brief.
We believe that the development and implementation of a command and 
control structure in a disaster situation is very critical to coordinate 
communications and the emergency response system at all levels.  This is 
just absolutely imperative.  The Government and private sector must work 
to ensure this is accomplished.  We stand prepared, and I know my 
colleagues do today as well, to work on this aggressively and to get it 
done and make sure this type of thing doesnï¿½t happen again without the
right type of communication and response.
A mechanism to track patients, as Congressman Burgess indicated, where 
transferred was applied in Hurricane Rita, where we have a number of 
hospitals in Texas.  It was somewhat more effective, but it needs to 
get better.  This will link patients to their needed care, to their 
family members, and to their physicians.  We think this is also critical.
Lastly, supplies were critical, and someone on the outside, such as 
myself, in a command center working to support our facilities and their 
ongoing need--and again, at the time of the storm, we had six in 
operation, we ultimately had to evacuate five--but trying to maneuver 
the various agencies to receive approval to get access to the area was
extremely cumbersome.  We did not know where to go or who to talk to or 
how long it would take.  We had the supplies, we had them staged and 
ready; we just couldnï¿½t get to them.
We are pleased to say that today, four of our six hospitals are in 
operation.  One in Biloxi, Mississippi as well, which often really 
doesnï¿½t get the recognition as the hospitals in New Orleans.  The same 
thing has happened here.
So, we believe our people were heroes.  We evacuated in excess of 5,000 
people from the region.  We believe we have done it successfully and we 
learned a lot of lessons.  Thank you for having us today. 
[The prepared statement of Robert Smith follows:]
Prepared Statement of Robert Smith, Senior Vice President, Regional 
Operations-Texas/Gulf Coast, Tenet Healthcare Corporation

Summary

As Senior VP of Operations for the Gulf Coast-Texas Region, I led 
Tenetï¿½s regional preparedness and response efforts to Hurricane Katrina 
and its immediate aftermath.  In my many years dealing with emergency 
preparedness, I have never experienced any natural emergency that reached 
the gravity and magnitude of Katrina.  
Emergency preparedness has been a priority for Tenet.  We have invested 
extensive resources to develop plans for many different situations.  
Each Tenet hospital had updated preparedness plans for hurricanes, 
electrical power interruption, floods, communications failure, and 
facility evacuation.
Tenet owns 6 hospitals in the Katrina impact zone.  As soon as the 
magnitude of the disaster became clear, we established two command 
centers.  One command center at Tenetï¿½s NorthShore Regional Medical 
Center operated as a de facto field hospital, from which we coordinated 
the influx of patients and hospital personnel from other hospitals 
throughout the region and the evacuation of those same individuals to 
facilities and locations outside of the affected region.
We also established a corporate command center in our Dallas 
headquarters, where we coordinated and oversaw the execution of our 
emergency plans both regionally and in each hospital.  We organized 
re-supply and evacuation efforts.  We quickly assembled a fleet of 
private helicopters, aircraft and buses.  Employee and patient locator
services, emergency pay, grants, temporary lodging and employment 
services, and volunteer management were also coordinated from our
headquarters in Dallas.
As a result of our experience during Katrina, I believe we need to 
reinforce a command and control structure that will provide for
communication and cooperation at all levels of response.  Without this
structure, it was difficult to get basic information and assistance on 
critical issues.
This tragedy has also reinforced the importance of communication in 
emergency situations.  I believe that all levels of government and the 
private sector should work together to ensure that communications are 
improved.  In addition, Tenet is developing and employing new 
communication safeguards and technologies to equip our hospitals.
Finally, in the case of emergencies for which there is advance warning,
such as hurricanes, critical supplies should be pre-staged for
expeditious delivery to the affected area.  

Chairman Whitfield, Congressman Stupak, Subcommittee members:
I thank you for inviting me to appear today before the Subcommittee.
My name is Bob Smith and I am Senior Vice President for Operations for 
the Texas/Gulf Coast Region for Tenet Healthcare.  Tenet Healthcare 
owns 69 hospitals across the country.  We own six hospitals in the 
Katrina impact zone.  In downtown New Orleans, in addition to Memorial 
Medical Center, there is Lindy Boggs Medical Center, a 188-bed hospital 
first opened in the 1920s as Mercy Hospital, and which includes the 
Transplant Institute of New Orleans.  In nearby Jefferson Parish, we 
operate Kenner Regional Medical Center, a 203-bed acute care community 
hospital in Kenner, and Meadowcrest Hospital, a 207-bed general medical 
and surgical acute care facility in Gretna.  NorthShore Regional Medical 
Center is a 174-bed acute care hospital located on the north shore of
Lake Pontchartrain in Slidell.  Finally, in Biloxi, Mississippi, there 
is Gulf Coast Medical Center, which consists of a 189-bed medical and 
surgical acute care facility and a 45-bed behavioral health facility.  
Prior to Katrina, together these hospitals employed approximately 5000 
people with an annual payroll in excess of $230 million, worked with
2500 affiliated physicians, and paid nearly $16 million per year in 
state and local taxes.
I have been asked by the Subcommittee to speak to Tenetï¿½s corporate-
level response to Katrina, and to offer some recommendations on dealing 
with future emergency situations.
I have worked in hospital management for over 28 years.  In that time, I 
have had many experiences planning for and handling emergencies.  That 
said, I have never experienced any emergency that approaches the gravity 
and magnitude of Katrina.  For our five hospitals in New Orleans, the 
damage inflicted by the storm itself was not significantly greater than 
other hurricanes weathered by Tenet hospitals in the past, but the 
catastrophic flooding that resulted due to failed levees completely 
destroyed the entire city and region.  Federal, state, and local 
governments were overwhelmed in their efforts to evacuate tens of 
thousands of citizens, and the resulting sense of chaos and desperation 
led to lawlessness and civil unrest.
What was unique about Katrina was the scope of the disaster.  More 
typical emergencies impact a local area, and resources can be readily 
brought to the facility and patients moved to other nearby hospitals.  
In contrast, Katrina affected every hospital in New Orleans, flooding 
made reaching some hospitals difficult or impossible, and multiple
hospital evacuations caused competing demands for all emergency services 
and private assets that could be used to aid evacuations.
Emergency preparedness has been a priority for our hospitals.  Over the
years we have invested a great deal of resources in developing plans for
many different situations and conducting emergency preparedness training 
in conjunction with local public safety officials.  But the devastation
caused by Katrina was truly unprecedented.  In a (for lack of a better 
term) normal emergency - be it a hurricane, earthquake, tornado or other 
event - severe damage tends to be relative
ly localized and the emergency response system focuses on getting 
resources such as command, communication and rescue teams into the 
affected area.  In the rare event that such damage requires the complete 
evacuation of a hospital, other unaffected facilities nearby move 
rapidly to accept evacuated patients and absorb the influx of victims 
seeking emergency treatment.  Yet as we all know, Katrina was not a 
normal emergency.  It involved the complete evacuation of an entire
urban center, much of it reachable only by boat or air, in an area 
surrounded by hundreds of other communities that had also been 
devastated by the storm.  Simply put, the situation completely 
overwhelmed government officials and private citizens at every level.  
For hospitals in New Orleans, especially those in the flood zone, that
meant moving thousands of critically ill patients hundreds of miles, 
often with little or no assistance or guidance from emergency officials.
At the time of Katrina, our Louisiana and Mississippi hospitals had 
updated preparedness plans for hurricanes, electrical power 
interruption, floods, communications failure, and facility evacuation. 
These plans were developed in close coordination with the Metropolitan 
Hospital Council, the Office of Community Preparedness and other 
public safety officials.  All of the plans contemplate coordination
with local public safety officials, such as fire, police, the 
Metropolitan Hospital Council and the Office of Community Preparedness.
In the days before Katrina made landfall, all six of our Gulf Coast
hospitals implemented their emergency response plans.  Ambulatory
patients were discharged, elective surgeries were cancelled, and
non-essential personnel were sent home and advised to comply with 
official evacuation orders.  Generators were checked, fuel was 
delivered, and the hospitals stocked up on food, bottled water, medical 
and other supplies to support patients and staff for up to four days. 
Senior corporate officials and I held conference calls with the hospital
management teams to check on preparations.
Things went pretty well throughout the storm on Monday.  Power was lost 
to the facilities, but back-up generators kept critical systems 
running.  There were sporadic communications problems.  A last minute 
change in the stormï¿½s direction focused the heaviest winds on Biloxi, 
and damage to Gulf Coast Hospital, located only a few blocks from the 
water, resulted in a decision to evacuate that facility immediately 
following the hurricane.
But as daylight came on Tuesday, we were pleased to find that our five 
New Orleans hospitals emerged with only moderate damage.  Like everyone
in the city, we thought we had "dodged the bullet" and that recovery 
crews would soon have everything back on the road to normal.  When the 
levees were breached on Tuesday, however, situations rapidly 
deteriorated across the city and at our hospitals.  Our hospitals were 
soon inundated with people and water, or they became isolated islands 
surrounded by flood waters.  This overwhelming force of nature also 
brought about a virtual collapse of the cityï¿½s infrastructure, leaving 
hospitals without power and with temperatures in excess of 100 degrees,
with virtually no water service, and with little available and
efficient access to provide supplies and assistance to address 
critical health care issues.
As a result: 
Memorial and Lindy Boggs were facing immediate and severe flooding 
issues with no short-term guarantee of assistance or help available;
Kenner and Meadowcrest had major public infrastructure issues and 
growing safety concerns;
Gulf Coast, which had been hardest hit by the hurricane winds, would 
have to evacuate; and,
NorthShore, which remained open, effectively became a field hospital 
because of the influx of patients from the surrounding area.
To address these very different situations, we assembled 2 major 
command centers:
One at NorthShore to help provide immediate guidance on the ground 
closest to the disaster.  This command center was key to ensuring that 
we could continue to serve the critical needs of the people during this
unprecedented time.  It is important to note that although NorthShore 
was several miles away from the lake, there were numerous water and 
flooding issues nearby that made conditions in Slidell treacherous and 
dangerous as well.  Given all the issues - the flooding of New Orleans, 
the need for assistance, and the mass exodus - NorthShore became 
overwhelmed with people.  The hospital CEO, Mike Oï¿½Bryan, later 
recounted of those days, "We started getting people in from all 
directions.  Some walked in, some swam in.  Helicopters were setting 
down on campus for the next 24 hours, and we had no idea what they were
bringing us - trauma, gunshot wounds - most of them were the walking 
wounded.  At that point, we turned every building into an acute field 
hospital.  Some folks were on stretchers in the hall.  We had folks 
lined up everywhere.  We were practicing field medicine." 
Also during this time, Tenet set up a corporate command center in 
Dallas.  The corporate command center consisted of about 50 company reps
from finance, HR, security, government relations, communications, travel,
and supply logistics departments.  Through this effort we oversaw the
strategic plan to begin the resupply of NorthShore, coordinating
airlifts of supplies and personnel into NorthShore.  We also had 
extensive communications with governmental authorities regarding 
evacuation plans.  This center also evolved as the strategy center 
after we received a phone call on early Wednesday morning.
In my office on Wednesday morning, I received a phone call from the 
Office of Emergency Preparedness indicating that if we wanted our 
patients, staff, and family members evacuated quickly, we should 
attempt to do it using private assets given the extraordinary strain on 
that officeï¿½s resources.  The corporate command center became vital to 
ensuring that we could do that.  After that call, I notified our CEO 
who quickly consulted with Ross Perot, Jr. to obtain an overview on 
undertaking a massive evacuation effort, including the necessity of
procuring security personnel to protect our patients and staff at our 
facilities.  With the command center coordinating resources, we 
arranged for helicopters, air ambulances and supplies for the major 
evacuation and resupply effort.
Through the coordinated efforts and hard work of many people, those 
tasks were achieved.  In retrospect, we are grateful and humbled by the 
humanitarian efforts we witnessed.
By late Wednesday night, Tenetï¿½s friends and contractors had airplanes,
helicopters, buses and ambulances headed to the New Orleans area in full
force.
Eight airplanes, five helicopters, 50 buses, 26 ambulances and 32 
security personnel were used to support the private rescue and resupply 
effort.
Cigna provided a jet for Tenetï¿½s use, as well as three semi-trucks of
food and supplies.
British Petroleum donated 1,000 gallons of unleaded gas and 300 gallons
of diesel to help keep NorthShoreï¿½s evacuation efforts functioning.
Aviation Services in Dallas provided five helicopters that ran multiple 
trips, moving personnel and supplies in and out of NorthShore.
Acadian Ambulance, one of the first private responders on the ground to 
assist Tenet, provided ambulances.
Dr. Kip Schumacher, a practicing physician, provided three trucks of
supplies and helped with local communications in the area.
We witnessed greatness from so many of our business partners and friends, 
and it was truly amazing to see how they responded in our time of 
greatest need.
Within our own corporation, many employees gave so much of themselves, 
going above and beyond, to try and help those in need as well.
At corporate headquarters, an Employee Disaster Assistance Center was 
created to handle the flood of calls from employees and families ranging 
from trying to reunite with loved ones to obtaining emergency pay checks 
to looking for temporary employment.  We had many employees who 
volunteered to work after hours, in addition to their regular jobs, to 
help staff phone lines or to do whatever they could to help during these
difficult times.
More than 1,000 employees from across the country volunteered through a 
corporate web site to provide assistance.  Some of those employees were 
mobilized to fly in to relieve teams of exhausted health care providers 
and employees at NorthShore, many of whom worked virtually around the 
clock for several days without rest until relief arrived.
Through this substantial effort, by Thursday evening;
Lindy Boggs had been evacuated with air assistance from the Fire 
Department and local residents using boats.
Memorial and Meadowcrest patients had been evacuated; and
Kennerï¿½s evacuation was complete by about 8 p.m. using both ground and 
air resources.
In addition, private aircraft took the last of Memorialï¿½s staff and 
employees out by midday Friday.  Then, aircraft that we had secured to 
help in our evacuation efforts were sent to assist with Charity, 
Methodist and University hospitals.
During and after the rescue, the command center also dealt with many 
other issues.  A critical function was locating patients evacuated from 
or through our hospitals.  This was extremely difficult, since we didnï¿½t 
have any reliable information on the destinations of patients not
evacuated by us, and early in the disaster no government agency provided 
a central locator system.  We also established an employee assistance
center to provide housing vouchers, emergency loans, 401(k) withdrawals, 
and grants to displaced employees, along with job relocation assistance.
Now I would like to share with the Subcommittee a few recommendations on 
how local, state and federal emergency response efforts can be improved
in preparation for a future disaster such as Katrina.  First, we must 
reinforce a command-and-control structure that will provide for 
communication and cooperation among all levels of response.  As I have 
already stated, the rescue needs created by Katrina throughout the Gulf 
Coast completely overwhelmed emergency response officials.  Clear lines 
of authority need to be established.  Without this authority, it became 
very difficult to get basic information on critical issues, such as 
obtaining flight clearance for rescue choppers, where non-patient 
evacuees should be taken, and even the final location of patients 
evacuated by the Coast Guard and others.
Second, all levels of government and the private sector should work 
together to ensure that communications are improved.  In response to our 
experience with Katrina, Tenet is developing and deploying new 
communication safeguards and technologies to our hospitals.  But that 
is only part of the answer.  Government officials must also invest in
such technology and take the lead in improving communications so that
communications throughout the entire emergency response system can be 
maintained in the face of a disaster.
Finally, in the case of a hurricane or other disaster for which there 
is advance warning, critical supplies such as fuel, spare generators, 
food and medical supplies should be pre-staged ready for delivery into 
the affected area.  Doing so effectively will require the cooperation 
of local and state emergency response officials to ensure the security
of deliveries and access to the disaster zone.
I am happy to say that progress is already being made on much of this, 
including procedures put into affect in Texas in advance of Hurricane 
Rita only three weeks after Katrina.
In the months since Katrina, three of the five evacuated hospitals, Gulf
Coast Medical Center in Biloxi, Mississippi, Kenner Regional Medical 
Center and Meadowcrest Hospital in Gretna, Louisiana have reopened for 
various levels of service.  North Shore Regional Medical Center in 
Slidell, Louisiana remained open throughout despite experiencing some 
hurricane damage.
Memorial Medical Center and Lindy Boggs Medical Center, in the heart of 
New Orleans, remained flooded weeks after Katrina struck.  They remain 
closed and full damage assessments are still under way.  We have 
announced the development of a new NOLA regional health network to 
continue to serve New Orleans and to restore service to both hospitals; 
it is yet unknown whether that means the existing sites need to be 
repaired or possibly rebuilt.
Thank you again for the opportunity to address the Subcommittee.  
Despite the huge cost Katrina has inflicted upon our hospitals, we 
remain a proud citizen of the communities in which our hospitals 
reside, and we remain committed to them. Returning healthcare services 
to the citizens of the Gulf Coast is critical to the rebuilding of the 
historic and economically vital region.  We will continue to work with 
federal, state and local leaders toward that end.
Thank you.
Mr. Whitfield.  Thank you.  At this time, we recognize Dr. Fontenot for 
her five-minute opening statement.
Ms. Fontenot.  Thank you, Mr. Chairman.  Thank you for the opportunity 
to share our Katrina experiences.
I believe that the Medical Center of Louisiana and New Orleans, as the 
designated regional disaster hospital provider was as prepared as we 
could have been for the horrible event that occurred on August 29.  As 
the regional hospital provider, our pre-Katrina disaster plans did not 
include evacuation.  Instead, we try to take care of disaster victims 
in the event of a hurricane or other natural disaster or emergency.  As 
a routine annual exercise, the hospital perfected Code Gray drills 
which included identification of employees and physicians who were 
assigned to be present and caring in University Hospitals, which 
comprised the Medical Center of Louisiana, for the duration of a weather 
event after the code is activated.
In the past, LMCO has activated Code Gray status about twice annually. 
The usual Code Gray activations last about two days and are then over 
with, with resumption of routine activities to follow.  This activation
was much different in that the hospitals, both Charity and University,
suffered substantial damage, including loss of electricity and water 
for the five days post-storm, forcing reliance on emergency generator 
power.  It was also necessary at this time to utilize additional 
supplies and equipment we had ordered as part of our annual preparation 
for hurricanes.
At the time of the storm, University Hospital had a census of 
167 patients, and at Charity, about 200.  I will provide you with a 
synopsis of our preparation.  It began the summer of 2000, when we 
purchased 1,000 5-gallon buckets with lids for future use as human 
waste containers.  On June 1st every year, we purchased an additional 
12,000 gallons of bottled water, 1,000 bottles of bleach, and 14 days 
of nonperishable food supplies above normal usage.  The specific 
Hurricane Katrina preparations began on Thursday, August 25, when we 
conducted dietary and pharmacy assessment of inventory in advance of 
the storm.  On Saturday 27, at 8:00 a.m., when Katrina crossed 
Florida and headed for the Gulf Coast, our CEO issued e-mails to all 
employees to inform them of a Code Gray watch in anticipation of 
evacuation.
Later that day, the administrative team met to review the Code Gray 
plans and the decision was made to activate the following morning.  
Physicians were notified to discharge all patien
ts who could be safely discharged.  Environmental assessments, 
movement of essential equipment, like water, body bags, and generators 
were accomplished that afternoon.  Sunday morning, August 28, at 
7:00 a.m., Code Gray activation began.  A Command Center was 
established at University Hospital, and prestaging of supplies and 
water bags was completed.
The patients were moved away from windows later in the afternoon as 
the wind approached tropical force.  On Monday we lost electric power 
at both campuses with emergency generators beginning automatic 
operation within two to three minutes without power loss.
At that point, about 3 feet of water surrounded the University, but the 
area, the streets outside of the Charity campus, were still dry.  
Rising water later in the afternoon led us to believe there must have 
been a levee breach because there was no more rain.  The sump pumps 
were still operating, but were ultimately overcome by rising water 
later in the day.  We lost running water.  Tuesday through Friday was 
spent treating patients, triaging patients for planned evacuation.  
Ultimate evacuation was accomplished on Friday, by both boats and 
helicopters, four days after the loss of power.  The loss of patient 
life was minimal and limited to critically ill patients.
Lessons learned from this disaster include the absolute necessity of 
reliable communication devices.  Hospital police radios were reliable 
but required frequent battery changes and recharging.  Cell phones were 
unreliable as were satellite phones.  Our HAM radio operator, who was a 
routine part of our hurricane preparedness, was effective in 
establishing contact; better coordination with governmental agencies to 
ensure communication between military, fire, and law enforcement 
personnel is required.  For example, if we could have had some notice 
that the levee system had failed rather than just watching as the water 
steadily rose, we could have anticipated the need for vertical 
evacuation; clearly, evacuation plans need improvement in the timeliness 
of getting critically ill patients out of devastated facilities.
The Medical Center of Louisiana historically has been a viable partner 
in planning for disaster preparedness, and we look forward to our future 
role and are committed to improve on the past and plan for the future.  
Thanks for the opportunity to talk here. 
[The prepared statement of Cathi Fontenot follows:]
Prepared Statement of Cathi Fontenot, Medical Director, Medical Center 
of Louisiana-New Orleans

Mr. Chairman and members of the committee, thank you for the opportunity 
to share our Hurricane Katrina hospital experiences with you.  I believe 
that the Medical Center of Louisiana at New Orleans, as the designated 
regional disaster hospital provider, was as prepared as we could have 
been for the horrible event that started on August 29.  
As the regional HRSA hospital provider, our pre-Katrina disaster plans 
did not include evacuation.  Instead, we prepared to take care of 
disaster victims in the event of a hurricane or other emergency.  
As a routine annual exercise, the hospital conducted "Code Grey" drills 
which included identification of employees and physicians who are 
assigned to be present in Charity and University Hospitals, which 
comprise the Medical Center of Louisiana, for the duration of a weather 
event after the code is activated.  
In the past, MCLNO has activated Code Grey status approximately twice 
yearly.  The usual Code Grey activations last about two days, and then
are over with resumption of routine activities. This activation was 
much different in that the hospitals (Charity and University) suffered 
substantial damage, including loss of electricity and water for the
five days post storm and forcing reliance on overwhelmed generator 
power.  It also was necessary to utilize the additional supplies and 
equipment we had ordered as part of our annual preparation for 
hurricanes. 
At the time of the storm, University Hospital had a census of 
167 patients and Charity, approximately 200.
I will provide you with a synopsis of our preparation:

Summer of 2000
Purchased 1000 5 gallon buckets with lids for future useï¿½as human 
waste containers.
ï¿½
June 1st annually
Purchase 12,000 gallons of bottled water, 1,000 gallons bleach, 
14 days of pharmaceutical stocks above normal usage, and 14 days of 
nonperishable food supplies above normal usage.
ï¿½
Specific Hurricane Katrina Preparations
ï¿½
Thursday 8/25/05
Conducted dietary and pharmacy assessment of inventories in advance 
of the storm.
ï¿½
Saturday 8/27/05
8 am:ï¿½ Katrinaï¿½crosses Florida and heads for the Gulf Coast.

11 am: CEO of MCLNO emails all employees to inform them of a Code Grey 
watch and anticipated activation.

2 pm:	Administrative team meets to review code grey plans and the 
decision to activate the following morning.  Physicians are notified to 
discharge all patients who can be safely discharged.

4 pm:  Notified department directors of Code Grey warning and plans for 
activation the following morning.  Environmental assessments and 
movement of essential equipment (water, body bags, generators) from 
warehouse to facilities completed.  Media notified ofï¿½ intentï¿½to raise 
Code Grey status to full activation
ï¿½
Sunday 8/28/05
7 am:  code grey activation begins.  Incident command center established 
at University campus.    Prestaging of supplies, generators, plywood and 
water vacuums completed.  Announcement made to media of closure of 
hospital to all but emergency services.  Patients moved away from windows 
as winds approach tropical storm force.
ï¿½
Monday 8/29/05
Loss of electrical power at both campuses with emergency generators 
beginning automatic operation within 2-3 minutes of power loss.  Three 
feet of water surrounded University campus.

Rising water late afternoon despite no rain.  Sump pumps operating in 
basements.  Pumps ultimately overwhelmed by rising water and hospitals 
dependent on portable generators.
Running water lost.
ï¿½
Tuesday through Friday, 8/30-05 - 9/2/05, were spent treating patients 
and triaging for planned evacuation.   The ultimate evacuation from 
both campuses was accomplished Friday 9/2/05 by both boats and 
helicopters, four days after the loss of power.
ï¿½
Loss of patient life was minimal and limited to critically ill patients.
ï¿½
The lessons learned from this disaster include the absolute necessity 
of improved and reliable communication devices.  Our hospital police 
radios were reliable but required frequent battery change and recharges.
Cell phones were unreliable, as were satellite phone systems.  Our Ham 
radio operator was effective in establishing contacts.  
Better coordination with governmental agencies to ensure communication 
between military, fire and law enforcement personnel is required.  For 
example, if we could have had some notice that the levee system had 
failed, rather than just watching as the water rose, we could have 
better anticipated the need for vertical evacuations inside the 
facilities.
Clearly, evacuation plans need improvement in the timeliness of getting 
patients out of such a devastated facility.  This will require careful 
planning with outside entities.  Heliports should be considered at any 
healthcare facilityï¿½for possible medical evacuations.
The Medical Center of Louisiana historically has been a vital partner 
in planning for disaster preparedness and we look forward to our future 
role.  We are committed to improve upon the past and plan for the future. 
Thank you for the opportunity to share our experiences.

Mr. Whitfield.  Thank you.  At this point, we recognize Mr. Don 
Smithburg for his five-minute opening statement.
Mr. Smithburg.  Thank you.  We appreciate you being on the grounds with 
us this week.
I represent the LSU Healthcare Services Division, which, before the 
storms, comprised nine of the 11 State public hospitals and over 
50 clinics that traditionally have been called the Charity Hospital 
system in Louisiana.  Our hospitals and clinics constitute the bulk of 
the healthcare safety unit for the Stateï¿½s uninsured and particularly 
the working uninsured.  Every individual in the State is eligible to 
receive services in any of our hospitals regardless of their State or 
parish or ability to pay.  Louisiana has one of the highest rates of 
uninsureds in the nation, 20 percent of the population, and is 
estimated to include over 900,000 individuals.  Another 22 percent of 
the population on top of that is on Medicaid.  And that was before 
Katrina and Rita.  Blue Cross and Blue Shield of Louisiana has recently 
issued a report that calls for an estimated 200,000 more citizens to 
join the ranks of the uninsured as the businesses that they work for 
failed because of the stormï¿½s destruction.
Not only is Louisiana a relatively poor State, but small employers are 
predominant in our economy.  Many, even in the best of times, cannot 
offer benefits and we have offered our surrogate health insurance 
program for businesses.  The healthcare safety net is essential to both 
provide access to care and to support a significant portion of our 
economy.  The LSU hospitals and clinics are the core safety net where 
the vast majority of medically indigent patients are hard-working 
individuals.  We are the only Level 1 trauma center to serve South 
Louisiana and much of the Gulf Coast.
Since the hurricanes, many patients in need of trauma care have been 
transported as far away as Shreveport and Houston, and other local 
hospitals have stepped forward to help take care of as much trauma care 
as they can reasonably handle.  It is not unreasonable to assume, 
unfortunately, that mortality rates will increase as a result of the 
lengthy transport times to trauma centers outside of the region.
LSU Hospital also has had an integral role in supporting the 
educational programs of our medical schools and training institutions 
and that includes not only LSU, but also our partners at Tulane and 
the Ochsner Clinic Foundation.
At Charity and University Hospitals alone, there are over 800 Tulane 
and LSU medical residents in training and thousands of nurses were 
in place when Hurricane Katrina struck our sister facility down the 
street.  I know you understand the destruction Charity felt here.  
Big Charity, as we call it, is the second oldest continually operating 
hospital in the United States.  It has been in place since 1736, 
almost 270 years.  It was destroyed once before by a hurricane, back 
in 1779, and it was replaced, prior to FEMA obviously, just five 
years later.
Having created a statewide Charity system, it is natural and 
appropriate that Louisiana would turn to this system in times of 
emergency.  Understanding emergency preparedness, our hospitals are 
designated as the lead facilities in the region to accept patients 
with special acute needs that may become emergent in a crisis.  We 
have regarded our hospitalï¿½s obligation to gear up in potential 
disasters and to continue to operate when others may not be able to 
do so.
LSUï¿½s emergency preparedness and our role in them were fundamentally 
sound to a point.  That point was surpassed by the cataclysmic loss 
by Katrina.  After flooding and losing power, Charity and University 
were unable to function as receiving facilities.  Our patients and 
our staff themselves needed to be evacuated.  We are looking for 
lessons learned as you are from the subsidiaries with an eye toward 
improving not only Louisianaï¿½s emergency preparedness, but also that 
of our Nation.
From our perspective, there are many lessons.  First, as this 
community is aware, it proved to be inadequate in ability or low 
priority to evacuate patients and staff at Charity and University 
Hospitals within a reasonable period of time.  In the future, we 
will not again assume that agencies that are physically and 
bureaucratically remote from our hospitals will come to our rescue. 
Instead, we will try to develop the means to transport patients 
should they need us, just as our colleagues do in the private 
sector.  Should assistance be available, gladly we will accept it 
and we will work with hospitals at any level to create an effective 
means to deal with all aspects of emergencies such as Katrina and 
Rita, but weï¿½ll also try to take care of our patients within our 
system with the limited resources we have.  In fact, when Rita 
threatened Southwest Louisiana just a few short weeks after Katrina, 
we did evacuate our threatened patients and staff from our hospitals 
in Lake Charles, Lafayette, and Houma, to our facilities in Baton 
Rouge and Alexandria, out of harmï¿½s way.  We did not wait for the 
established cavalry, as we did after Katrinaï¿½s floods.  We became 
our own cavalry and took care of ourselves without asking for or 
accepting help and it worked.
Another lesson is the need for reliable communication.  I canï¿½t 
emphasize it enough.  Both in New Orleans and Bogalusa, where our 
hospital received extensive storm damage, communications with our
central office in the State Emergency Command Center and others 
was exceedingly difficult.  In the case of Bogalusa, there was 
silence for two days.  Police radios worked in New Orleans but 
only intermittently.  HAM radio was the most reliable and the 
technology will continue to be investigated, but it is slow.  
Text messaging on cell phones, interestingly, worked, while cell
phones often did not.  Satellite phones were generally useless. 
Although several different technologies failed or were of limited 
use, communications undoubtedly needs a logical solution.
Cooperation across levels of government needs to be improved, in 
my view.  There appeared to be no sense of command at the office of
emergency preparedness where I was anchored during the storm.  
State agencies that were accustomed to working with each other were 
respectful of each other, communicating and coordinating seemingly
well.  The United States Health Service was a godsend to the region. 
Because the scale of this event was so massive, there were other 
Federal agencies that responded, but did not seem to be nearly as 
fluent in intra-agency communication and coordination.  It is in 
part because of that problem that we took complete control of our 
fate when Rita threatened Southwest Louisiana.
It is not enough to have disaster plans.  We must understand that 
when we call for them, we need to be prepared to implement them.
Moving towards closing, despite the designated roles of our 
hospitals in New Orleans to receive evacuated patients, we received 
far more than we had capacity for.  I personally worked at the State 
Command Center headquarters to both move patients and staff from 
Charity and University to other hospitals across the State, but 
this approach, the planned approach was overruled.  Instead, 
patients from our hospitals in New Orleans were taken to the New 
Orleans Airport, ultimately put on a military transport, and 
scattered across the country.  Only the medical records that our 
staff taped to our patients left with the patients.  But no staff, 
while we asked for it, no staff could accompany them, and to our 
knowledge, no record was kept of who was on what plane, where they 
came from or where they were going.
Now, we know that improvements can and must be made in our capacity 
to handle hurricanes and other emergencies.  It is fair to focus on 
the emergency preparedness system, but at the moment, we have too 
few staff to even participate in the next catastrophe.  The next bus 
crash, as you noted, could have happened in New Orleans, but it 
happened in Jacksonville, Florida.  Today USA Today covered it.  If 
that crash had occurred here, where in that case regrettably there 
were seven deaths, I donï¿½t think our system could handle it.
Existing hospital emergency departments are taxed, but even in the 
best of circumstances, there is no substitute for an extensive 
public primary specialty clinic network.  Medical education in New 
Orleans that serves the needs of the entire State could be destroyed 
if not.
Mr. Chairman, we deeply thank you for being on the ground today with
our committee and we looked forward to working with you in meeting 
these unprecedented challenges.  Thank you. 
[The prepared statement of Donald R. Smithburg follows:]
Prepared Statement of Donald R. Smithburg, Executive Vice President-
LSU System, Chief Executive Officer, LSU Health Care Services 
Division

Summary

The LSU Hospitals and Clinics are the core of Louisianaï¿½s safety net 
for the uninsured and the principal sites for the training programs
of the LSU and Tulane medical schools.  Charity Hospital in New 
Orleans was also the only Level 1 Trauma Center serving South 
Louisiana and much of the Gulf Coast.  Both Charity and University 
Hospitals are closed due to damage from Hurricane Katrina, and both 
experienced significant problems associated with a flawed reaction 
to the emergency created by the storm.  
The experience of Charity and University Hospital represents an 
opportunity to improve the system of emergency preparedness in 
Louisiana and the nation.  However, the destruction of these hospitals 
means that there are no public facilities in the region to participate 
in improved processes.  Our first priority is to restore the capacity 
of our public health care system and then to work with other agencies 
at all levels to improve our capability to respond cooperatively to 
emergency situations of all types. 	
The major areas in which improvement in emergency processes is needed 
include the ability to evacuate patients in a safe, timely and organized 
manner when conditions warrant; the technical ability to communicate 
and exchange information with those outside the hospitals during a 
crisis; and the development of seamless working relationships with 
federal officials, as well as among state agencies, so that emergency 
plans can be implemented or, if appropriate, altered in a coordinated 
manner.  

Mr. Chairman and members of the committee, I want to thank you for 
coming to Louisiana.  We will be grateful for whatever assistance you 
can provide, but your willingness to visit our state is itself a 
gesture that we deeply appreciate.
	I represent the LSU Health Care Services Division, which 
	comprised 9 of the 11 state public hospitals and over 
	350 clinics that traditionally have been called the "charity 
	hospital system" in Louisiana.   I would like to begin by 
	describing this system in brief.
	Our hospitals and their clinics constitute the vast bulk of the 
	health care safety net for the stateï¿½s uninsured and 
	underinsured, particularly the working uninsured.  Every 
	individual in the state is eligible to receive services in any 
	of our hospitals regardless of the parish in which they live or 
	their ability to pay.  Louisiana has one of the highest rates 
	of uninsurance in the nation, over 20 percent of the population, 
	and estimated to include over 900,000 individuals (and another 
	22 percent are on Medicaid).  That was before Katrina and Rita. 
	Blue Cross of Louisiana has recently estimated that 200,000 
	more individuals will join the ranks of the uninsured as 
	businesses fail because of the stormsï¿½ destruction.  
Not only is Louisiana a relatively poor state, but small employers are
predominate in our economy.  Many, even in the best of times, cannot
offer benefits, and we often are a surrogate insurance program for 
business.  A health care safety net is essential to both provide access 
to care and to support a significant portion of our economic base.  
The LSU Hospitals and Clinics are the core of that safety net.  The 
Charity campus also supported the only Level 1 Trauma Center that serves
South Louisiana and much of the Gulf Coast.  Since the hurricanes,
many patients in need of trauma care have been transported to 
Shreveport and Houston.  It is not unreasonable to assume that 
mortality rates will increase as a result of the lengthy transport 
time.
 	The LSU hospitals also have had an integral role in supporting 
 	the education programs of our medical schools and training 
 	institutions, and that includes not only LSU but also Tulane 
 	and the Ochsner Clinic Foundation.  At Charity and University 
 	hospitals alone, there were around 800  Tulane and LSU medical 
 	residents in training when Katrina struck and destroyed our 
 	facility.  
	I know you will understand that the destruction of Charity 
	Hospital is felt especially deeply here.  "Big Charity" was the 
	second oldest continuing hospital in the nation and has endured 
	as one of the most significant medical institutions in the 
	nation over the 270 years since its founding in 1736.  It was 
	destroyed once before by a hurricane, in 1779, but rebuilt just 
	five years later.  Today, it sits in ruins a short distance from 
	here.
	Your states  -  and almost every state  -  have some system that
	fulfills the same functions as the LSU hospitals and clinics.  
	Outside Louisiana, however, the provider safety net for the 
	uninsured is most often a local governmental function.  You 
	undoubtedly are familiar with county or district hospitals or 
	comparable programs that have as their predominant mission 
	assuring access to care regardless of ability to pay.
Having created both a statewide and a public hospital system, it is 
natural and appropriate that Louisiana would turn to this system in 
times of emergency.  Under state emergency preparedness plans, our
hospitals are designated as the lead facilities in each region to 
accept patients who have special acute needs that may become emergent 
in a crisis or catastrophe.  We have regarded it as our hospitalsï¿½ 
obligation to gear up for potential disasters and to continue to 
operate when others may not be able to.   We have the capacity as a 
system to transfer patients to our facilities in other parts of the
state, if necessary.  And since Louisianaï¿½s only Level I trauma and 
specialty care centers  -  in New Orleans and Shreveport  - are 
operated by LSU, special medical needs can be accommodated internally.
	Louisianaï¿½s emergency preparedness plans, and our role in 
	them, were fundamentally sound up to a point, but clearly that 
	point was surpassed by the magnitude of Katrina in the 
	New Orleans area.   After incredible flooding and loss of all 
	power, Charity and University Hospitals were unable to 
	function as receiving facilities as disaster plans call for, 
	and our patients and staff themselves required evacuation. 
You are looking for the lessons from this disaster with an eye toward 
improving not only Louisianaï¿½s future emergency preparedness but also 
that of the nation.  From our perspective, there were several general 
lessons and many others at the hospital operational level.  
	First, as this committee is aware, there proved to be 
	inadequate ability  -  or insufficient priority  -  to evacuate 
	patients and staff at Charity and University Hospitals within 
	a reasonable period of time.  In the future we will not again 
	assume that agencies that are physically and bureaucratically 
	remote from our hospitals will come to our rescue.  Instead, 
	we will develop the means to transport patients should the 
	need arise.   Should assistance be available, we will gladly 
	accept it, and certainly we will work cooperatively with 
	agencies at any level to create an effective means to deal with
	all aspects of emergencies such as Katrina and Rita.  But we 
	will also exercise our capacity to take care of our own 
	patients within our system.  
	In fact, when Rita threatened Southwest Louisiana a few short
	weeks after Katrina, we did evacuate threatened patients and 
	staff from Lake Charles, Lafayette and Houma to facilities in 
	Baton Rouge and Alexandria.  We didnï¿½t wait for the established 
	cavalry as we did after Katrinaï¿½s floods.  We became our own 
	cavalry and took care of ourselves without asking or expecting 
	help.  And it worked.
	One major lesson from this crisis was the need for reliable 
	communications.  Both in New Orleans and Bogalusa, where our 
	hospital received serious wind damage, communications with our 
	central office, the State Office of Emergency Preparedness and 
	others were exceedingly difficult.  In the case of Bogalusa, 
	there was silence for two days.   Our police radios worked in 
	New Orleans, but only intermittently in about 45 second 
	intervals.  Ham radio was most reliable, and it is a technology 
	we will continue to invest in  -  but it is slow.  
	Interestingly, cell phone text-messaging worked in a number of 
	cases even though cell phone conversations often did not.  
	Satellite phones were generally useless for us.  Although 
	several different technologies failed or were of very limited 
	use, the communications problem undoubtedly has a technological 
	solution.  We need to determine the best way to stay in touch 
	in emergencies, and put the appropriate equipment into the right 
	hands.
	Coordination across levels of government must be improved.  
	There appeared to be no sense of command at the Office of 
	Emergency Preparedness (OEP).  State agencies that are 
	accustomed to working with each other, or just respectful of 
	one another, communicated and coordinated well.  But possibly 
	because the scale of the disaster was so massive, the 
	various federal agencies that responded did not seem to be 
	nearly as fluent in intra-agency communication and 
	coordination.  It is in part because of that problem that we 
	took complete control of our fate when Rita threatened us in 
	Southwest Louisiana.
	It is not enough to have disaster plans.  We must understand 
	what they call for and be prepared to implement them unless 
	unforeseen and overriding factors arise.  To give you one 
	concrete example, despite the designated role of our hospitals 
	to receive evacuated patients, we received far fewer than we 
	had capacity for.  I personally worked at the state Office of 
	Emergency Preparedness headquarters to move both the patients 
	and the staff from Charity and University to other LSU 
	hospitals that were prepared to accept them, but this 
	approach  - the planned approach  -  was overruled.  Instead, 
	patients from Charity and University Hospital were taken to 
	the N.O. airport, ultimately put on military transports and 
	scattered across the country.  Only medical records, but no 
	staff, accompanied them.  To our knowledge, no record was kept 
	of who was on what plane, where they came from or where they 
	were taken.  
	Immediately after the evacuation, it was as if our patients had 
	disappeared, and when the calls from families came asking about 
	those in our care, we could not tell them where they were.  
	Staff spent literally weeks calling hospitals across the country 
	asking if any patients from Charity or University hospital had 
	been transferred there.  Despite these efforts and those of the 
	Louisiana Hospital Association, we never did find out where all 
	our patients were taken.  
	We know that improvements can and must be made in our capacity 
	to handle hurricanes and other emergencies.  It is fair to focus 
	on the emergency preparedness system, but at the moment we have 
	too few hospitals standing to even participate in the next 
	catastrophe.   The next bus crash or minor emergency will 
	overwhelm current hospital capacity.  Existing hospital 
	emergency departments are taxed, but even in the best of 
	circumstances they are no substitute for an extensive public 
	primary and specialty clinic system.  Medical education in 
	New Orleans, which serves the needs of the entire state, could 
	be destroyed if appropriate training sites are not 
	re-established quickly. 
	LSUHCSD stands ready to assist the federal government in 
	repairing and strengthening our nationï¿½s emergency response 
	capacity.  But in Louisiana, a necessary first step is 
	restoration of the core capacity of our public health care 
	system.  Rapid and successful restoration of that capacity will 
	contribute to the public safety and is certain to save lives.  
	Thank you again for your interest and for this opportunity to 
	share LSUï¿½s insights into this critical issue.

Mr. Whitfield.  Thank you.  At this time, we recognize Mr. Sewell for 
his five-minute opening statement.
Mr. Sewell.  Mr. Chairman, members of the committee, I want to thank 
you for inviting me here to testify on behalf of Chalmette Medical
Center.  My name is Jon Sewell, and I serve as the CEO at Chalmette 
Medical Center in Chalmette, Louisiana.  CMC is owned and operated by a 
subsidiary of Universal Health Services and served the residents of 
St. Bernard Parish.  CMC had 230 beds that provided a wide array of 
services, including cardiac surgery, orthopedic, hyperbarics, and a 
30-bed ICU.  Annual admissions were approximately 9,000 and emergency
room visits approximately 25,000.
CMC, until it was destroyed by the hurricane, was the only inpatient 
and emergency room providing for St. Bernard Parish.  Over the seven 
days prior to the hurricane, or Hurricane Katrina making landfall, 
hospital officials working with the local Emergency Preparedness 
Council and watched the storm closely.  For most of the time, the 
hurricane was not considered to be a threat.  As of 11:00 a.m. Friday, 
in fact, it was still supposed to hit the panhandle of Florida.  It 
became of greater concern Friday at 5:00 p.m. and projections moved 
it farther west to Gulfport, and by Saturday morning, the projected
landfall was approximately at New Orleans.
CMC decided Saturday morning to implement its disaster plan.  We had 
cancelled elective surgeries the prior day and began to discharge 
patients who had any means of evacuation.  Attempts to transfer 
patients to other hospitals in the region were stalled because of 
the storm track being so wide.  Any hospitals within 100 miles 
were potentially in harmï¿½s way and reluctant to admit patients.  Plans 
to transport patients were scarce, as there was a lot of competition 
from nursing homes and special needs patients at other hospitals.
CMC then began discussions with its sister hospital, Methodist 
Hospital, to attempt to transport as many patients there as possible, 
as they had a taller structure and a more secure emergency power 
system.  Sunday was spent moving all ICU, inpatient rehab, psych, and 
skilled nursing patients to Methodist.  This was achieved using a 
combination of school buses for ambulatory patients and ambulances for 
more critically ill patients.  We lost ambulances on Sunday afternoon 
and began preparations for riding out the remaining storm.  We had 
approximately 200 staff and family members in the hospital.
Our disaster plan had also called for movement of all essential 
supplies to the top floor of CMC, including food, water, 
pharmaceuticals, and other clinical supplies.  We had ordered 
supplemental supplies earlier in the week and our final stash was 
estimated to last between four and five days.
As you all know, the western eye of the storm passed over 
St. Bernard Parish around 8 a.m. Monday.  Some roofs were peeled 
back and two windows blown in, but by 9:00 a.m, we had already 
begun to have discussions about moving patients and supplies back 
down to the first floor, when the flooding started.  By the time 
it ended, we had approximately 14 feet of water around us.  Our 
emergency generators flooded at about 10:30 that morning.  Cell 
phones were inoperative by noon.
At that point, we had no power and no air conditioning.  We had no 
communications with anyone outside of the hospital, with the 
exception of two-way radio communications to the fire department.  
While
the fire department was very helpful and supportive, they were not 
located in the same building as the sheriffï¿½s department or the Parish 
Command Center.  We were never able to make direct contact with any 
other parish or governmental agencies during the duration of the storm.
Shortly after the storm had subsided, approximately 200 local citizens 
who had not evacuated showed up at the hospital seeking medical 
attention and shelter.  They came by boat, and in some cases were quite 
ill.  Three patients were brought in suffering from acute distress.  
These patients were all stabilized and eventually transferred out of the
hospital.  This nearly doubled the population of the hospital and became
a significant distraction and security threat.  With the assistance of 
the local sheriffï¿½s department they were all transported by boat to a 
local parish shelter by Tuesday.
Also on Tuesday, parish officials arrived by boat to inform us that a 
MASH unit had been set up at the local jail with power and air 
conditioning and recommended transferring our patients there.  On 
Wednesday morning, we began transferring by boat all patients to the 
ER, to the jail, with the help of the parish fire department and Good 
Samaritans.  As we transferred patients, we also sent medical staff, 
supplies, and other clinical staff to support the patients during their 
stay at the MASH unit.  All patients were transferred by Wednesday 
afternoon.
On Thursday, helicopters began arriving to evacuate remaining employees 
and family members.  I was among the last members of this group to 
leave.  We were taken to Louis Armstrong Airport and were initially 
placed in the MASH unit, which contained approximately 2,000 patients 
at that point.  The unit was clearly understaffed
 And our group offered to assist in providing patient care to those 
 patients in the MASH unit.  The offer was accepted by the emergency 
 physician in charge, who was charged with oversight of the unit.  
 Nearly all of the employees of CMC volunteered to help render medical 
 assistance to these patients, whether they were lying on stretchers
 on the floor or on luggage carousels.
After an hour, we were approached by an official with FEMA who ordered
us away from the patients because we were not authorized by FEMA to 
provide patient care.  We were then placed in the general population 
of the airport.  At around midnight, another health system, HCA--thank 
you very much--offered us transportation out of Lafayette on buses--or 
to Lafayette on buses it had secured.
Notably, during the four days following the storm, the hospital 
received no supplies from any Federal or state agencies and very 
limited supplies from the local parish.  USH had immediately after the 
flooding secured helicopters to deliver food, water, and other supplies, 
and although those efforts were frustrated by difficulty in getting 
access to air space, eventually some of those supplies were delivered 
to Methodist Hospital.
UHS had also set up a command center to provide assistance to families 
seeking information, whether the information was on patients at those 
hospitals or employees.  Methodist provided as best they could updated 
information in its most accurate form.
In closing, I would like to recognize all of the doctors and staff, 
family members of staff, the first responders from the parishï¿½s sheriff 
and fire department for providing extraordinary care during one of this
Nationï¿½s greatest natural disasters.  I was privileged to witness a 
group of people who were soon to become refugees themselves, rise up 
and work collectively to ensure that our patients were provided with
the highest possible care.  I can honestly say that I witnessed more 
acts of heroism and courage during this crisis than anyone could 
imagine.
Thank you very much for inviting me here today. 
[The prepared statement of Jon Sewell follows:]
Prepared Statement of Jon Sewell, Chief Executive Officer, Chalmette 
Medical Center, Universal Health Services, Inc.

My name is Jon Sewell. I served as the CEO for Chalmette Medical Center
(CMC) in Chalmette, Louisiana. CMC is owned and operated by a subsidiary
of Universal Health Services (UHS) and served the residents of St Bernard 
Parish, and to a lesser extent those of Orleans Parish.
CMC had 230 beds and provided a wide array of services including cardiac
surgery, orthopaedics, hyperbarics, and a 30 bed I.C.U. The hospitalï¿½s
annual admissions totaled approximately 9,000 and emergency room visits 
approximately 25,000. CMC, until it was destroyed by the hurricane, was 
the only Inpatient and Emergency Room provider in St Bernard Parish.
Over the seven days prior to Hurricane Katrina hitting landfall, 
hospital officials, the Hospital Chief of Staff , and the local 
Emergency Preparedness Council watched the storm closely.  For most of 
that time, the hurricane not considered a threat because as of  11 a.m. 
on Friday morning, Katrina was projected to hit the Florida panhandle. 
It became a greater concern when a Friday 5 p.m. projection had the 
storm center projected to hit near Gulfport, Alabama. By Saturday 
morning, the projections had moved the storm landfall to somewhere near 
the New Orleans area.
CMC decided Saturday morning to implement its disaster plan. We had 
already canceled elective surgeries the prior day and began to discharge 
any patients who had a means of evacuation. Attempts to transfer 
patients to other hospitals were stalled because the storm track had 
been so variable that any hospitals within a hundred miles were still 
potentially in harms way and were reluctant to admit patients. 
Ambulances to transport patients were also scarce because many special 
needs patients, nursing home residents and other hospitals were all 
attempting to move patients at the same time. 
CMC then began discussions with itï¿½s sister hospital, Methodist Medical 
Center, to attempt to transport as many patients as possible because 
Methodist had a taller structure and a more secure emergency power 
system.  Sunday was spent moving all ICU, Inpatient Rehab, Psychiatric
and Skilled Nursing patients to Methodist. This was achieved by using a 
combination of school buses (for ambulatory patients) and ambulances 
(for more critically ill patients). We lost access to ambulances 
sometime Sunday afternoon and began preparations for riding out the 
storm with the remaining patients. At that time, our census was 
47 patients, and approximately two hundred staff and family members 
were at CMC.
Our disaster plan called for the movement of all essential supplies to 
the second floor (CMCï¿½s top floor), including food, water, 
pharmaceuticals, and other clinical supplies. We had ordered 
supplemental supplies earlier in the week and our final stock was 
estimated to last four to five days, if required.
As you all know now, the Western eye of the storm passed over 
St Bernard Parish around 8 a.m. Monday. Some roof was pealed back and 
two windows were blown in. By 9:00 a.m., we thought the worst had 
passed and we were considering a plan to move patients and supplies 
back to their original locations, but then the flooding started. By 
the time the flooding ended, we had approximately 14 feet of water. 
Our emergency generators flooded at approximately 10:30, and cell 
phones were inoperative by noon. At that point, we had no power, air 
conditioning or communications with anyone outside of the hospital 
with the exception of a two-way radio link to the Fire Department. 
While the Fire Department was very supportive, they were not located 
in the same building as the sheriffï¿½s department or the Parish command 
center. We never were able to make direct contact with any of the other 
Parish government agencies.
Shortly after the storm had subsided, 200 local citizens who had not 
evacuated began showing up at the hospital, seeking medical attention 
and shelter. They came by boat and, in some cases, were quite ill. Three 
patients were brought in suffering from acute distress.  These patients 
were stabilized by hospital personnel. The number of refugees nearly
doubled the population of the hospital and became a significant 
distraction and security threat. With the assistance of the local 
sheriffï¿½s department, they were all transferred by boat to the Parish 
shelter on Tuesday.
Also on Tuesday, Parish officials arrived at the hospital by boat to 
inform us that a MASH unit had been set up at the local jail with power 
and air conditioning. Parish officials recommended that the hospital 
consider transferring itï¿½s patients to the MASH unit. 
On Wednesday morning, we began transferring patients by boat to the 
shelter with the help of the Parish fire department and local good 
Samaritans. As we transferred patients, we also sent medical staff and 
supplies to support the patients during their stay at the MASH unit.  
The transportation of all patients was completed by Wednesday, mid 
afternoon.
On Thursday, a helicopter from the National Guard arrived to begin 
evacuating the remaining employees and their family members. I was among
the members of this group. We were taken to Louis Armstrong International 
Airport and placed in the MASH unit there which contained nearly 2000 
patients. The unit was clearly understaffed and our group offered to 
assist in providing patient care to the MASH unit. The offer was 
accepted by the emergency physician charged with oversite of the unit. 
Nearly all of the employees present volunteered to help render medical
assistance to the patients lying on stretchers, the floor or on luggage 
carousels. After about an hour, we were approached by an official with 
FEMA who ordered CMC staff away from the patient area because we were 
not authorized by FEMA to provide care in the MASH unit. We were then 
placed in the general shelter population of the airport.
Around midnight, another health care system, HCA, offered the group from 
Methodist and CMC transportation to Lafayette on buses they had secured. 
Notably, during the four days following the storm, the hospital received
no supplies from any federal or state agencies and very limited supplies 
from the local Parish. UHS, our management company, had immediately 
after the flooding secured helicopters to deliver food, water, fuel and 
other supplies. Although those efforts were frustrated by difficulties 
in getting access to airspace eventually some of those supplies were 
delivered to Methodist Hospital.
UHS also set up a command center immediately after the storm to provide 
assistance to families seeking information regarding UHS patients and 
employees at CMC and Methodist who provided patient care during the storm
and to keep them updated with the most current and accurate information 
available.
Finally, I would like to recognize all of the doctors, staff, family 
members of staff, local citizens and first responders from the Parish 
sheriffï¿½s and fire department for providing extraordinary support during 
one of this nationï¿½s greatest natural disasters. I was privileged to 
witness a group of people, soon to become refugees themselves, rise up 
and work collectively to ensure that our patients were provided the best 
care possible. I can honestly say that I witnessed more acts of heroism 
and courage during this crisis than anyone could imagine.

Mr. Whitfield.  Thank you, Mr. Sewell.  At this point in time, we recognize
Mr. Muller for his five-minute opening statement.
Mr. Muller.  Mr. Chairman and members of the committee, thank you for 
inviting me to testify today on behalf of West Jefferson Medical Center, 
and a special thank you to you all for coming to our region in this 
great country.
West Jefferson Medical Center, located ten minutes from downtown New 
Orleans, is a 451-bed public hospital and health system with programs 
and services across the complete continuum of care.  We are one of only 
three hospitals out of 15 that remained open after Hurricane Katrina 
struck.  We did not lose a single patient due to the storm.  Ironically, 
we were three months out from opening a new energy and support services
facility, a model for the Nation, which would be 20 feet above sea 
level.  West Jefferson Medical Center did not flood but did sustain over 
$2 million in damages.
Personal visits after the storm from Congressman Michael Burgess--thank 
you, sir--Congressman Rodney Alexander, also Congressmen Jindal, 
Melancon, and Jefferson, visits by Senator David Vitter, Secretary 
Michael Leavitt, Vice Admiral Carmona, Mark McClellan, and Dr. Julie 
Gerberding lifted our spirits and advanced our personal mission to 
succeed.
FEMAï¿½s response to employ a DMAT, which we personally requested the day 
after the storm and discussed with Senator Vitter, was admirable.  The 
DMAT disaster hospital that did support our emergency department was 
noteworthy.  In future disasters of this magnitude we would, however, 
request that DMATs be more immediately available.
We are exploring more extensive communication systems moving forward, 
and to install an on-site water well at the hospital.  We are exploring 
the cost and feasibility of elevating structures for critical services 
such as building our new emergency room on the second floor instead of 
the first.  The storm exposed the deficiencies of our State healthcare 
system.  Louisiana historically has suffered from a dearth of primary 
and specialty ambulatory care capacity available for low-income and 
other consumers.  A lack of this capacity coupled with low Medicaid 
rates for physician care and no mechanism to reimburse clinicians for 
any indigent care has led to an over-dependence on emergency rooms and 
an inadequate ability to care for low-income patients.  Charity and 
Medicaid DHS funds were concentrated at one delivery system and were 
not aimed at medical centers of Louisiana.  Remaining providers are 
absorbing patients without any payments.  Medicaid DHS money did not 
follow the patient.
Our operating losses since Hurricane Katrina have totaled more than 
$28 million.  West Jefferson worked closely with our congressional 
delegation to identify existing Federal legislation that could provide us 
financial relief.  We worked to offer language to the Stafford Act that 
would make our hospitals eligible for a Community Disaster Loan Program.
Parallel to this effort were discussions with CMS, providing regulatory 
relief to the Stark Amendment, which would allow us the opportunity to 
provide assistance to physicians practicing in our hospitals.  We must
receive the CDL this month to provide for our physicians.  West 
Jefferson is committed to retaining a physician workforce for our region 
and has been in conversation with both LSU and Tulane University Schools 
of Medicine.  We are in the process of applying for major teaching 
hospital status, but continued concern over reimbursement issues has 
hindered our efforts.  The Louisiana Hospital Association, LSU and 
Tulane are seeking an extended waiver from CMS to allow residents to 
keep training in alternative locations, namely private hospitals like 
us.  The current waiver expires on January 31.  We understand that CMS 
has yet to issue an extension.  With the departure of our DMAT hospital,
we need to create a separate entity, a community health center to 
provide emergent care services close to our emergency.
As we rebuild the healthcare delivery system, one consistent 
recommendation has been the immediate expansion of community-based 
primary care and mental health services.  Potential Federal legislation 
or regulatory relief should include expediting an extension of CMS 
waiver for residents, allowing hospitals operating in immediate 
disaster areas the option of cost-based reimbursement on an inpatient or
outpatient basis, providing for funding to follow patients cared for by 
health practitioners enrolled in residency programs, and provision of 
special dispensation for funding federally qualified health centers in 
the areas affected by Hurricane Katrina.
At the local and regional level, we also should enhance communications 
systems whether it is HAM, satellite, or VoIP.  Also, facilitating 
improvements such as raising most facilities above flood level, 
enforcing regional cooperation and cooperation among hospitals, and 
finally sharing our updated hurricane plans, as we are all doing with 
the local and State emergency operation centers.
Together, we will make a difference.  Thank you all very much for your
time today.
[The prepared statement of Gary Muller follows:]
Prepared Statement of A. Gary Muller, President and Chief Executive 
Officer, West Jefferson Medical Center

Mr. Chairman and Members of the Committee:
Thank you for inviting me to testify today on behalf of West Jefferson 
Medical Center. 
West Jefferson Medical Center, located 10 minutes from downtown New
Orleans, is a 451-bed community hospital and health system with 
programs and services across a complete continuum of care.  
West Jefferson rediscovered itself as a leader during Hurricane Katrina 
through the resiliency and resourcefulness of our doctors and staff. 
We did not lose a single patient due to the storm. 
West Jefferson stayed the course during Katrina.  We are building 
stronger. Ironically, we were three months out from opening a new Energy 
and Support Services facility, a model for the nation. West Jefferson 
Medical Center did not flood but sustained over $2 million in damages.
West Jeffersonï¿½s story goes beyond bricks and mortar.  I am proud of our 
doctors and staff and grateful for their actions during the disaster.
They put aside their personal tragedies and fears to respond to the 
hospitalï¿½s needs.  
The post-Katrina story is complex as we embrace challenges continually. 
Only 1/3 of the pre-Katrina hospital bed capacity in the New Orleans 
area is available. Providers of all types that remained operational are 
experiencing significant financial losses as we struggle to retain 
health care workers and deliver care
The regionï¿½s labor and operating expenses have inflated dramatically
without corresponding payment increases. Hospitals have also experienced 
a dramatic rise in indigent care. 
Establishing emergency communications early with the local EOC was 
invaluable. Personal visits and information from Congressman Michael 
Burgess, Congressman Rodney Alexander, Senator David Vitter, Secretary 
Michael Levitt, Vice Admiral Dr. Richard H. Carmona, Dr. Mark McClellan
and  Dr. Julie Gerberding lifted our spirits and advanced our personal 
and professional drive to respond not only to West Jeffersonï¿½s citizens 
but to the region. 
FEMAï¿½s response to deploy a DMAT which we personally requested through 
Dr. Carmona and discussed with Senator Vitter was admirable. The DMAT 
Disaster Hospital that supported our Emergency Department was 
noteworthy. Together, the DMAT staff and our teams were able to 
administer more than 40,000 doses of vaccine. In future disasters of 
this magnitude, we would request the DMAT units to arrive earlier. 
In summary, we will be better prepared for the future because of what 
we are doing today. We are exploring a more extensive communication 
system and moving forward to install an on-site water well at the 
hospital. We are exploring the cost and feasibility of elevating 
structures for critical services such as building our new Emergency 
Room on the second floor instead of the first. 
We must also arrange for a well-honed process for back-up relief teams.
Personnel worked for days on end without relief. West Jefferson Medical
Center plans to develop a closer relationship with the state EOC for 
earlier communications. 
 The storm exposed the deficiencies of our health care system. 
 Louisiana (and the affected areas) historically has suffered from a
 dearth of primary and specialty ambulatory care capacity available for 
 low-income and other consumers. The lack of capacity, coupled with 
 low Medicaid rates for physician care and no mechanism to reimburse 
 clinicians for indigent care has led to over dependence on our 
 emergency rooms and inadequate access to care for low-income, uninsured
 patients.
Charity care and Medicaid DSH funds concentrated at one delivery system 
and not well integrated with other community care delivery points - as 
MCLNO has downsized, remaining providers are absorbing patients without
adequate payments. 
Medicaid DSH money "did not follow the patient" to other provider 
settings. 
Financial survival has become top priority for WJMC and we have focused 
efforts to explore every regulatory or legislative mechanism that might 
assist us. Interestingly, the present situation has offered us the 
chance to collaborate with organizations that may never have been viewed 
as partners. Our operating losses since Hurricane Katrina total more 
than $28 million dollars. 
West Jefferson Medical Center and East Jefferson General Hospital, both 
Service District Hospitals, worked closely with our Congressional 
Delegation to identify existing federal legislation that could provide 
us financial relief. We worked diligently to offer language to the 
Stafford Act that would make our hospitals eligible for a Community 
Disaster Loan Program. Parallel to this effort were discussions with 
CMS providing regulatory relief of the Stark Amendment which would 
allow us the opportunity to provide assistance to physicians 
practicing at our hospitals. We must receive the CDL this month to 
provide for our physicians as the Stark waiver will expire on 
January 31st. 
LSUï¿½s medical school program, which trains three out of every four
doctors in this state, was severely impacted by Hurricane Katrina. 
WJMC is committed to retaining a physician workforce for our region 
and has been in conversations with both LSU and Tulane University 
School of Medicine. We are in the process of applying for major
teaching hospital status, but are concerned that GME reimbursement 
issues will hinder our efforts. For example, the LHA, LSU and Tulane 
are seeking an extended waiver on CMS caps to allow residents to keep 
training in alternative locations, namely private hospitals. The 
current waiver expires on January 31st . We understand that CMS has 
yet to issue an extension.
With the departure of our DMAT hospital, we made an agreement with a 
separate entity to provide urgent care services close to our emergency
room. As we rebuild the healthcare delivery system, one consistent 
recommendation has been the immediate expansion of community based 
primary care and mental health services.
Due to Congressional budget cuts within HHS, there will be no new 
grant funding for FQHCs in this fiscal year , so Louisiana will have 
to receive special dispensation for funding (by way of an earmark 
appropriation) if we are to develop new, grant funded FQHCs. 
Lessons learned from experiences should result in policy changes that 
will benefit everyone in the future. Potential legislation or 
regulatory relief should include:
Allowing adjustments to the wage index calculation based on disaster 
related rate increases.
Provision for adjustments to the outlier methodology and thresholds 
to reflect the lack of post-acute care capacity. 
Expedition and extension of CMS waiver for resident caps 
Allowing  hospitals operating in immediate disaster areas the option 
of cost-based reimbursement on an inpatient and/or outpatient basis.
Provision for funding to follow patients cared for by health 
practitioners enrolled in residency training programs
Provision of special dispensation for funding Federally Qualified 
Health Centers in the areas affected by Hurricane Katrina
Increased communications and collaboration between legislative and 
executive branches of government for the recovery efforts on the 
Gulf Coast

At the local and regional level we should:
Enhance communications and communication systems
Facilitate facilities improvements 
Forge regional cooperation and collaboration among hospitals 
Share our updated Hurricane Plans with local and state EOC 

Together, we will make a difference. Thank you for your time today. 

Mr. Whitfield.  Mr. Muller, thank you.
At this time, those of us here on the panel will each have ten minutes 
to ask questions, and Iï¿½m going to watch this clock rather closely, 
because we do have another panel, but it is such an important hearing 
we want to give all the Members ample opportunity to ask their 
questions.
Mr. Muller, let me ask you the question, you made reference to the fact 
that a disproportionate share of payments go to hospitals for indigent 
care in the State of Louisiana.  I suppose because of State law, that 
funding goes only to the LSU Charity Hospital systems.  Is that correct?
Mr. Muller.  There are other hospitals that have a high proportion of 
uninsured or Medicaid.  West Jefferson, for example, is below that. 
Most hospitals are.  A very, very large percentage of all those funds 
goes to the LSU system.  
Mr. Whitfield.  Well, is it a disproportionate share that goes to the 
LSU system or not?  
Mr. Muller.  In my opinion it is, because there are unmet needs in 
many, many, many other providers in the State of Louisiana that do not 
receive a dime from any of those funds.  
Mr. Whitfield.  But today, because Charity is not in operation, and
University is not in operation, are you being reimbursed at all for 
care given to indigent patients?  
Mr. Muller.  No, sir.  
Mr. Whitfield.  Now, that is not Federal law, is it, or is this a State 
law that causes it to be this way?  
Mr. Muller.  There are two levels, to my understanding.  One is the 
State applies to CMS and the Federal government for matching funds.  
That comes into the State of Louisiana and then, the State of Louisiana 
disburses those.  So, I believe it really is mostly controlled at State 
level.  
Mr. Whitfield.  I think that is right, because obviously, the Federal 
dollars match and provide a good portion of the Medicaid costs, but each 
State decides for itself the way a lot of that is dispensed and so forth.
Let me ask you, all of you on this panel, who has the responsibility, 
legal or otherwise, to evacuate patients when you have a situation like
Katrina, a disaster, really, of epic proportion?  Does the Federal 
government have any responsibility in that evacuation, making that 
decision?  Who makes the decision to evacuate?  
Ms. Fontenot.  At our institution, the CEO, our commander, basically 
makes the decision to evacuate, of course, in conjunction with 
Mr. Smithburg, who is the CEO of the hospital system.  But to my 
knowledge, that is where the decision lies.  
Mr. Muller.  Mr. Chairman, in Jefferson Parishï¿½s instance, the emergency
operations state thatï¿½s controlled by the parish president and we 
receive direct orders because we are a parish facility.  
Mr. Whitfield.  But you donï¿½t have to obtain approval from the Federal 
government, or I guess any government agency to evacuate patients; that 
is a decision for you to make to protect your patients under the 
conditions that are there that day, or are present?  
Mr. Muller.  That is correct.  
Mr. Whitfield.  Now, Congressman Stupak mentioned in his opening 
statement, the stark contrast between the Tulane University and Charity 
and University Hospitals.  They are relatively close, both of them; all
of them were flooded.  Iï¿½m assuming that the major difference--I mean, 
the Tulane hospital is going to be up and operating for limited services
relatively soon, and I donï¿½t get the impression that University and the 
Charity Hospital are going to be in a situation to do that anytime soon 
now.
Iï¿½m assuming and I want you all to correct me if I am wrong, but one of 
the big differences here is that HCA is operating the Tulane hospital, 
and that is a private for-profit corporation, and so, they are putting 
their private dollars in, their investorsï¿½ dollars in, and yet, at 
Charity and University, you are totally depending, Iï¿½m assuming, on the 
government, either local, State or Federal government, in order to get
you back in operation.  Is that correct?  Or is that not correct?  
Mr. Smithburg.  Mr. Chairman, that is generally correct.  With regard to 
Charity and University, in fact, all of the LSU hospitals, because we 
are public entities and derive most of our funding from public dollars, 
actually most institutions do, but because we are in the public sector, 
we rely on public resources.  As you might imagine, we were stretched 
thin financially to begin with.  We had used reserves that we had 
accumulated from all of our hospitals to help deal with the tragedy, 
though.  
Mr. Lagarde.  Speaking from Tulane, our funds for reopening are property 
and casualty insurance as well as business interruption.  So, ours is 
not necessarily funded by the company, but it is funded by insurance.  
Mr. Whitfield.  What about Charity and University, was there insurance 
in place at the time?  
Mr. Smithburg.  Mr. Chairman, we fall under the Stateï¿½s Office of Risk 
Management, and it is our understanding that that self-insurance policy 
has about $500 million per occurrence for Rita, for Katrina.  That is
for the entire State infrastructure.  
Mr. Whitfield.  Thatï¿½s self insurance?  
Mr. Smithburg.  That is my understanding and Iï¿½m not an authority on 
that.
Mr. Whitfield.  So the State is responsible for that.  
Mr. Smithburg.  And keeping in mind that the $500 million for the 
Katrina episode was to cover not only the hospitals, but every piece of 
public infrastructure for which the State had responsibility.  So, we 
then rely, Mr. Chairman, rely on FEMA as the public entity.  We are 
theoretically FEMA eligible.  
Mr. Whitfield.  Now, we have heard a lot today about lack of Level 1 
emergency healthcare in the area, which certainly is vital.  Now, it is 
my understanding that Charity has received approval from FEMA for FEMA 
to pay the entire cost to have Charityï¿½s trauma center relocated to 
Elmwood Hospital in New Orleans.  Now, is that correct, or is that not
correct?  
Mr. Smithburg.  Of course, there are no answers in all of these kinds 
of general conclusions.  What FEMA has agreed to is that our lease of 
Elmwood can be reimbursed by FEMA.  We have not seen the funding for 
it.  And Elmwood is a private facility, owned by Ochsner, and they 
have offered it to us for one year.  So, FEMA has agreed that we can 
be reimbursed for it.  
Mr. Whitfield.  So that is a temporary solution for one year?  
Mr. Smithburg.  Yes, sir.  
Mr. Whitfield.  And do you have any idea when you can expect to see 
money from FEMA for this one-year fix?  
Mr. Smithburg.  Mr. Chairman, I have no idea when we will see the 
reimbursement from FEMA for any of our project worksheets that have 
been submitted.  
Mr. Whitfield.  Well, Iï¿½m assuming you canï¿½t open until you receive the 
money.  Is that right?  
Mr. Smithburg.  We are going to have to figure out a way to front it, 
and we are working very closely with our State.  
Mr. Whitfield.  I have just been told a few minutes ago that FEMA, into 
Louisiana, has provided either directly or indirectly, $406 million for
healthcare.  Do you-all have any knowledge of that particular figure or 
is that a figure that is just out of the air, or does anyone have any 
thoughts on that?  
Mr. Smithburg.  From LSUï¿½s point of view, that is the first time we 
have heard that number.  We have about $50 million of reimbursement 
requests in to FEMA.  
Mr. Whitfield.  Another area I want to look at briefly--obviously, on 
the backup power, that is something that you-all are going to be
addressing and where it is located and so forth--but when you are 
evacuating patients under emergency situations like this, I think for 
HCA and maybe even Tenet, perhaps, I donï¿½t know, but you are basically
sending your patients to other entities that you own.  
Mr. Lagarde.  Thatï¿½s what we do.  
Mr. Whitfield.  But it would seem to be relatively easy to keep up with 
the patients, and you know where these patients are.  But I get the 
impression that in the Charity Hospital situation, that these patients 
were being moved to airports and transported, and no one really--FEMA 
or whoever was responsible--did not really keep track of who went 
where.  Is that accurate or is that not accurate?  
Mr. Smithburg.  That is accurate.  We had plans to evacuate.  We are 
not set up to evacuate out of New Orleans.  We are the facility that is 
supposed to be the last standing as the trauma center.  But we had made 
our own plans to evacuate our patients to other LSU hospitals out of 
harmï¿½s way.  We donï¿½t have a fleet of helicopters or ambulances.  We 
have to rely on public services.  We submitted a plan and we were 
overruled.  
Mr. Whitfield.  By whom?  
Mr. Smithburg.  Iï¿½m not sure.  It was my understanding that FEMA said 
they had had another evacuation and deployment plan in place.  
Mr. Whitfield.  How many days did it take you to totally evacuate the 
Charity Hospital and University Hospital system?  
Mr. Smithburg.  Well, we got out on Friday, and the storm hit Sunday.  
Mr. Whitfield.  So, five to six days.
Well, my time has expired so Iï¿½m going to recognize Mr. Stupak for ten 
minutes.  
Mr. Stupak.  Thank you, Mr. Chairman.  So little time and so many 
questions.
First of all, Mr. Chairman, I would like to introduce in the record a 
letter of September 6 to the Secretary of HHS Michael Leavitt; a letter 
of September 20 to Chairman Barton; a letter from November 4 to David
Walker, comptroller of the U.S. Government Accountability Office; and
again, December 15, a letter to Secretary Leavitt, Department of Health 
and Human Services, signed by myself, Mr. Brown and Mr. Waxman on many
of these questions we have here today on preparedness and things like 
that.  So, we would like to have that in the record.  Thank you.
[The information follows:]


Mr. Stupak.  To all of our witnesses today, thank you very much for 
appearing today and thank you for all the work you have done.  It goes 
without saying your efforts truly are heroic and not only at the time 
of the hurricane and shortly thereafter, and yet your are still here 
today.  One of the disappointments I do have is that we donï¿½t have 
anyone from FEMA here to testify.  When we just get word--and did 
receive word--that $406 million has been spent in Louisiana, we donï¿½t 
know if it is for total health care or for the whole State or what it 
was for.  Thatï¿½s why I wish they would have been here.
Let me go a little bit more because I again raise the contrast between 
HCA and Charity and how it all came about and how it strikes me as we 
have one entity up and running and yet others are struggling to get up 
and running.  There is no doubt about it, that financial resources are 
a part of that.  Mr. Montgomery, you said most of your money was
probably insurance money?  
Mr. Montgomery.  That is correct.  
Mr. Stupak.  Did you receive any money at all from FEMA or HHS, for 
evacuation or--
Mr. Montgomery.  No. 
Mr. Stupak.  When you evacuated your patients, they went to other HCA 
hospitals, correct?  
Mr. Montgomery.  That is primarily true.  Childrenï¿½s Hospital, one in 
Texas and one in Little Rock.  
Mr. Stupak.  Mr. Muller, did you testify that your patients went from
your hospital, to the airport, or was that you, Mr. Sewell?  
Mr. Sewell.  Our patients were transported to a MASH unit set up at the
parish jail.  We were not informed where their ultimate designation was 
going to be.  In fact, I think a lot of those decisions were being made 
while patients were in the air.  
Mr. Stupak.  Who was making those decisions?  
Mr. Sewell.  I couldnï¿½t tell you that.  I believe we were being 
evacuated by the National Guard.  And I think they were trying to 
determine locations for the patients.  
Mr. Stupak.  The thing that struck me, one of you two gentlemen 
testified that you went to the airport, asked if your healthcare 
professionals could help out, and they did and then were told no, they 
could not help out.  Then people were dispersed around the country and 
the only way their records were with them, they were taped to the 
person?  
Mr. Sewell.  There were two or three different testimonies there.  I 
did relate the story of our staff --
Mr. Stupak.  Who made that decision, that you had to move them out of 
the airport and your staff couldnï¿½t help out?  Medical personnel who 
are trained, licensed, or certified and you are shorthanded, but they 
were not allowed to help out.  Who would make a decision like that?  
Mr. Sewell.  I couldnï¿½t tell you.  My observation was, there were a lot 
of different agencies at Louis Armstrong Airport, and a lot of very 
well-intentioned people who were trying to help, but there was little, 
if any, coordination, and I think a lot of people who were trying to 
help were very frustrated in their inability to help.  
Mr. Stupak.  Was Louis Armstrong Airport ever designated, prior to 
Katrina, as a site where you would bring patients who needed medical
attention?  
Mr. Sewell.  I donï¿½t know that.  I believe FEMA established that site 
using DMAT on Tuesday night, prior to even being authorized by the 
Governor to do that.  I think FEMA acted on their own initiative and 
set that up.  
Mr. Stupak.  Mr. Smithburg, todayï¿½s Times-Picayune says "New Orleans 
Given a New Lease on Life.  General Care Trauma Facility to Return by 
the Fall."
Is that true or is that a poke and a hope?  
Mr. Smithburg.  I would like to quote you, Mr. Stupak.  I would 
characterize our situation at University Hospital as one where FEMA has
agreed to a work order to bring up parts of University Hospital 
temporarily, and the initial work order was for about $13 million, and 
it is my understanding--although I canï¿½t prove it here under oath--it
is my understanding that once FEMA gets into a project, they will 
continue it through to the end, even if the initial work order did not
cover the entire expense.
I think that they way overestimated our situation.  We are moving in 
the right direction, but let me assure you, the committee is moving 
heaven and earth to get to this point, when as you all so eloquently 
said, the needs of this community are so desperate.  So, we are moving
in the right direction and we are cautiously optimistic, but I wonï¿½t 
believe it until it happens.  
Mr. Stupak.  Okay.  And you said FEMA now has offered $13 million to 
help you make that transition?  
Mr. Smithburg.  Yes, sir.  
Mr. Stupak.  In your estimation, is that going to be enough to cover
it?  
Mr. Smithburg.  I donï¿½t think so.  Again, it is my understanding of 
FEMA regulations that once they commit to a project, they will see 
it through.  I think there will be a lot more damage that is not 
visible to the naked eye once destructive testing is done.  In the 
case of Charity, we donï¿½t expect we can ever bring that back up online 
for healthcare purposes.  
Mr. Stupak.  That is the older Charity?  
Mr. Smithburg.  Yes.  As a temporary facility, we think we could, with 
baling wire and chicken wire.  
Mr. Stupak.  How far is University from Charity?  
Mr. Smithburg.  Just a couple of blocks away.  
Mr. Stupak.  Why are they up and running, and you still do not even 
have the lights on?  
Mr. Smithburg.  I canï¿½t say for sure why Tulane is up and running, but
I think it is because, in part, as Mr. Montgomery noted, they do have 
insurance, private insurance, or business interruption insurance.  
Mr. Stupak.  Is it an issue of financial resources?  
Mr. Smithburg.  I think it is a combination of an issue of financial 
resources, but also, the condition of the facilities.  I can only speak 
for mine, and thatï¿½s because of our very restrained resources over 
time, we have not been able to reinvest in the physical plant, so 
clearly our buildings are kind of starting with one arm behind their 
back before the storm.  
Mr. Stupak.  Your tent facility that I mentioned, at the Convention 
Center, that has been there since early October.  Correct?  
Mr. Smithburg.  We have been operating in tents since October, whether 
it was in the parking lot or in the Convention Center.  
Mr. Stupak.  Have you been reimbursed for any of that care since then 
by FEMA or HHS?  
Mr. Smithburg.  No, sir.  Millions of dollars really--
Mr. Stupak.  Have you applied to FEMA or HHS for reimbursement?  
Mr. Smithburg.  We have applied to HHS for a waiver to apply.  
Mr. Stupak.  Have you received that waiver?
Mr. Smithburg.  No, sir.  
Mr. Stupak.  How long have you been waiting for the waiver?  
Mr. Smithburg.  I will have to check in the record, but I believe, 
Mr. Stupak, we began talking to them about that--
Mr. Stupak.  Why do you need a waiver to provide this healthcare-- 
Mr. Smithburg.  Our understanding is that under CMS regulations, in 
order to be reimbursed, you provide care in what is considered standard 
of care facilities, such as regular hospitals or doctorsï¿½ offices.  
Mr. Stupak.  But it is also my understanding that JAHCO has approved 
your hospital, right?  The tents?  
Mr. Smithburg.  Yes, they have.  
Mr. Stupak.  Is that proof, then, for HHS, or do you need more to give 
HHS?  
Mr. Smithburg.  HHS has to do their own independent inspection.  
Mr. Stupak.  Is that inspection going to be sometime before March 7, 
before you close?  
Mr. Smithburg.  I hope so, sir.  
Mr. Stupak.  Any date set?  
Mr. Smithburg.  Not to my knowledge.  
Mr. Stupak.  You also pointed out several weaknesses in the disaster 
preparedness system, including the nonfunctional communications system, 
lack of a clear chain of command, particularly at the Federal level, but
most importantly, you stated that the emergency response cannot exist 
until a core capacity of the public health system is restored.  What do
you see as the first step in restoring that system?  
Mr. Smithburg.  Trying to identify what safety assets are available in 
the community and making them available for healthcare use regardless 
of Government structure or any of the other typical issues one deals 
with before a catastrophe hits--that we find a way to access those and
have the resources to back up our facilities.  
Mr. Stupak.  And you have done that with this one hospital that you are 
hoping to have open--
Mr. Smithburg.  We are finishing the paperwork on it, yes, sir.  
Mr. Stupak.  You have identified and now we need the Federal government 
to give you those waivers to reimburse you for your care and to get 
into this new facility as soon as possible?  
Mr. Smithburg.  We have reason to believe that once we occupy the 
Elmwood temporary trauma center, that that will be standard of care as 
an existing hospital.  
Mr. Stupak.  Any more questions on waivers, Mr. Chairman?  
Mr. Whitfield.  Thank you.  Dr. Burgess, you are recognized for ten 
minutes.  
Mr. Burgess.  Well, Mr. Smithburg, on the subject of waivers, when 
Secretary Leavitt came to Dallas and spoke at our medical facility, it 
was set up rather quickly, but there had been waivers granted because 
they understood these patients were being seen in facilities that were 
not standard Medicare-certified hospitals.  So, that has not happened
in Louisiana?  
Mr. Smithburg.  It has not.  And I have spoken with the Secretary and 
the CMS Administrator and his deputies, and certainly, in conversation 
they are inclined.  Regretfully, it has not happened yet.  
Mr. Burgess.  With the--and I guess you heard my frustration earlier 
there, there are probably $200 million of disproportionate share funds 
from September 30 to December 31 from the last quarter of the year.  
Mr. Smithburg.  I canï¿½t swear to that.  
Mr. Burgess.  There are millions of dollars available, and again, I 
just canï¿½t understand why those funds couldnï¿½t be made available to you 
to reimburse you for the care that you are delivering.  What is the 
obstacle there?  How can we help you get past that?  Because it makes 
no sense.  These are not new dollars that have to be appropriated from 
somewhere else and we have to find offsets.  These are dollars that are 
there sitting in some account, unspent.  And you have doctors leaving the
area because they cannot get paid, and your own employees are just 
staying out of their own good graces.  Is there a way we can help you 
access those funds--is the State part of the problem here?  
Mr. Smithburg.  Dr. Burgess, I think you are right in your assertions 
and I think all of my colleagues share in the same sentiment that 
getting access to those DHS dollars is of paramount importance. 
Keeping in mind a comment made by Congressman Jindal, our State 
government, constitutionally, there are only two areas that can be cut 
and that is education and healthcare.  The State has got its own 
economic disaster as well.  The special session in the legislature in 
November, they went through a budget-cutting process.  $200 million 
budget cut out of New Orleans was done.
As you probably know, the DHS program, you have to put up State-
matching and draw-down Federal dollars.  The State is having a 
challenge in generating its own match.  So, with some of the Medicaid
legislation that has been proposed, well, Medicaid legislation and 
other legislation, to have a Federal match taking place at the State 
level for at least some period of time, as relates to DHS, that will 
be helpful as well.
Then, there probably does need to be some liberalizing of 
disproportionate share allocation once it gets to the State, so that 
nontraditional teaching hospitals would have access to at least 
temporary dollars.  
Mr. Burgess.  I know in our State we got a waiver that allowed for I 
think one hundred percent Federal dollars.  There was no State match 
required for treating the displaced persons from the storm.  So again, 
if we can help you get that, that you need that designation--again
Iï¿½m having trouble why you have not gotten it already--we ought to be 
able to help you do that.  
Mr. Smithburg.  Thank you.  
Mr. Burgess.  Mr. Sewell, I did visit your facility earlier. 
Mr. Muller and his group brought me there.  I have to tell you my heart
goes out to you.  It looks exactly like the hospital I used to practice
in.  I can just imagine what it must have been like for you and your 
staff.  I did hear that same story about your doctors not being allowed
to participate in the care of their own patients out at the airport.  
I think Mr. Muller told me a similar story about the Lakefront airport. 
Perhaps there is a way, from a hospital or medical staff perspective, 
that we can help those people gain the credentials they need to get to 
be part of the federally certified task force, because it is under the 
control of the Federal government, as I understand it.
Again, Iï¿½m new at this and I have trouble understanding the bureaucracy 
and why it is necessary.
HCA has done great things with the DMAT teams.  I had not known you 
had done that.  I think it was a tremendous effort to be able to 
provide that sort of backup to the guys here on the ground.
I saw Mr. Muller in your parking lot that day in October, just doing a 
phenomenal job, and taking care of a great number of people in a timely
fashion that otherwise would have just put additional pressure on your 
doctors, in the emergency room.
I will have to say as a resident of Texas and someone who watched the 
tropical storm Alicia that came through Houston, no levees broke, but 
it rained 36 inches in an hour and Houston is low, like New Orleans, 
and they had a lot of trouble with the medical center.  And talking
about lessons learned, okay, I donï¿½t know if it is a JAHCO problem or 
just a hospital problem, but we have got to do a better job.  Again, 
Mr. Muller, I thank you for having the foresight to do that and get that
stuff off the ground.  Unfortunately, it just didnï¿½t quite get done 
before the disaster, but clearly it will happen again in low-lying 
areas.
The same stories of doctors and nurses having to carry the patients down
six flights of stairs to the cardiac care unit and bagging them the 
whole time, that was the story out of Houston in 2001.  A reasonable 
person might have predicted that New Orleans was also at risk for a 
similar sort of event.  Again, I think that is something that needs to 
be taken care of through the industry and not the Federal government. 
We talked about lessons learned, and that seems to be one of them.  But 
it does keep happening.
We saw the article in the paper this morning, Mr. Smithburg, and what--
it seems like there have been more obstacles in your path to get things 
up and running, and I guess Iï¿½m having a hard time understanding, are 
those obstacles that we at the Federal level are putting in your way or 
the State is putting them in your way?  Is it just the overall mess of 
your hospital that has made it more difficult to achieve the same sort 
of results as across the street with the rebuilding effort?  
Mr. Smithburg.  The best I can do, Dr. Burgess, to respond to that is 
to know that in our environment, the public hospital environment which 
is also the professionï¿½s training program, 70 percent of the health
professionals of the State swing through Charity Hospital one way or 
the other, so we need to find homes for residents and other trainees, 
either public or private, that have been devastated by the storms. 
So, at the same time, we are essentially an arm of the State government
with its own budget problem.  At the same time, trying to work through
with FEMA and in particular, I learned through my colleagues at Houston 
and spent a lot of time with people through lessons learned.  FEMA is 
clearly a marathon, but we are in a sprint environment right now, and
so, trying to figure out how to cross that Rubicon of long-term 
planning under the FEMA paradigm with todayï¿½s needs is a challenge and
we need your help.  
Mr. Burgess.  I would just say, I spoke about the safety net, and 
the hospitals have stayed open, they are certainly to be commended 
for preserving that.  I have to say what I saw your guys doing and the 
graduate medical student education efforts are continuing, I know that 
is how you get doctors in your area, is because you train them here 
and a certain number will stay.  That is a tremendous effort put forth
by your emergency room doctors and in the tents there at the convention 
center.  That is one of the most encouraging things as far as what does
the future look like going forward.  To me that is one of the most 
encouraging things I have seen down here.
Are you planning on being open by Mardi Gras?  
Mr. Smithburg.  We hope so.  
Mr. Burgess.  This year?  
Mr. Smithburg.  Yes, sir, we hope so.  Right now, the inevitable paper 
chase has us bogged down.  We know what it will take to turn it into a 
converted trauma center.  It will take four to six weeks.  Weï¿½re ready 
to roll, it is just a matter of it happening.  
Mr. Burgess.  Mr. Muller, as a representative of one of the only 
hospitals open during the storm and the aftermath, you have heard 
people talk about Level 1 trauma centers.  Obviously, by default, you 
are the trauma center right now.  Is that correct?  
Mr. Muller.  That is correct.  
Mr. Burgess.  And your doctors, neurosurgeons, orthopedists, general
surgeons are taking that load upon themselves at this point.  Is that
not correct?  
Mr. Muller.  That is exactly correct.  
Mr. Burgess.  So the stories we hear about four hours to get care, that
is not always true, because your hospital has been open and able to 
service those patients?  
Mr. Muller.  Thank you for mentioning that.  We do it every day and 
are glad to do it.  
Mr. Burgess.  How are you looking to get reimbursed?  
Mr. Muller.  Waivers to have the money follow the patient.  Again, we 
are working through the bureaucracy, basically at the State level.  
Mr. Burgess.  That is an important concept.  Mr. Chairman, if I may.  
The same thing is true with school children:  The money needs to follow 
the students and the money needs to follow the patients.  We need to 
take that message back.  
Mr. Whitfield.  Thank you.
Ms. DeGette, you are recognized for your ten minutes.  
Ms. DeGette.  Mr. Muller, you are not certified as a Level 1 trauma 
center, youï¿½re just doing it because you have to do it in the breach, 
correct?  
Mr. Muller.  Correct.  
Ms. DeGette.  You are not pursuing Federal certification as a Level 1 
trauma center, are you?  
Mr. Muller.  No, maï¿½am.  
Ms. DeGette.  You do need to go get those monies from those waivers, from
the DHS money and the other money to be able to sustain this in the short 
run, correct?  
Mr. Muller.  Yes, maï¿½am.  
Ms. DeGette.  You canï¿½t, over the long run, become a Charity-type 
hospital, thatï¿½s not your hospitalï¿½s business plan or your mission, 
right?  
Mr. Muller.  Right.  
Ms. DeGette.  I can assume, Mr. Lagarde and Mr. Montgomery, you are
doing everything you can and you are going to be doing everything you 
can, but in the long run, your mission is not to be a Charity Hospital 
either.  
Mr. Lagarde.  Thatï¿½s correct.  
Ms. DeGette.  I just want to say we are in awe of everybody here.  
This whole committee is.  What we saw yesterday at Charity, what we saw
yesterday at HCA was amazing to us.  When we saw where you were talking
about the heart patient and the MASH unit, and where folks were walking 
up and down stairs with that person, and that person lived, I mean, that
was extraordinary to us.  I just want to preface by saying we think 
everybody in the private and public sector really fulfilled their
mission as healthcare professionals, and I want to thank you on behalf 
of the American citizens for that.
And I also want to say, the other thing that struck some of us 
yesterday was how much faster the private hospitals have been able to 
get back on their feet because they have private insurance money.  And, 
really, Charity has been left kind of, as often happens, holding out 
their cup, begging for Federal and State assistance.  And I really want 
to focus on that.  Because I think everybody here would agree, we have 
to get the hospital back up and running.  I mean, we have 1 million 
people who, before the hurricane in the New Orleans area, did not have 
health insurance.  And while people can help collaboratively, and they
have been, in the long run, we are going to have 65 percent of the 
people come back, which is what the projections are, and we have to get
them some health care.
And so, I want to ask you, Mr. Smithburg, in your written testimony 
you said a necessary first step is restoration of the core capacity of 
our public healthcare system.  Can you just tell me briefly why you 
think that is true?  
Mr. Smithburg.  Looking at the projections of the population, it is 
almost like nailing Jello against the wall.  And it changes regularly. 
But what we foresee, at least at LSU, is that while the population may 
be smaller in New Orleans proper, there is a reasonable chance the 
number of uninsured, at least the whole number, is going to rise for 
the foreseeable future.
When you think about the renaissance of New Orleans, it is going to be 
built in large part on the backs of low-income workers doing dangerous 
work with little or no access to healthcare.  The community hospitals 
are already taxed.  As you noted, their business plan does not plan 
for a long-term care of the public patients as it does for us.  That 
is our mission.
And so, in order to attract people to come back here, in addition to
the work, we have to have some sort of healthcare infrastructure, a
safety net, we believe, to accommodate the growing needs, healthcare 
needs, chronic and acute.  
Ms. DeGette.  Mr. Smithburg, when you came back to Washington and 
talked to the Secretary and others, did they seem to agree with you 
that we need a strategic plan to restore health care for those folks in
New Orleans?  
Mr. Smithburg.  The "they" in your question requires a number of 
different answers.  There certainly have been some who left--elected 
officials or appointed officials who are sympathetic, and in fact, we
achieved a great deal of sympathy and we have tried to transfer that
into waivers or special dispensations for funding and the like, and in
many cases, that has been forthcoming.  
Ms. DeGette.  Has anybody from the Federal government or State talked 
to you about working collaboratively for a specific plan to restore 
the core healthcare plan for the New Orleans area?  
Mr. Smithburg.  Really, it is--
Ms. DeGette.  Or is it more ad hoc with the waivers and so on?  
Mr. Smithburg.  As it relates to LSU, we clearly have a strategy that 
relates to trying to get waivers, trying to lease assets that may be 
available for the public healthcare needs.  I canï¿½t say that there is
a plan per se forthcoming at either the Federal or State level.  
Ms. DeGette.  It is really being driven by your plan?  
Mr. Smithburg.  Yes, maï¿½am.  
Ms. DeGette.  Let me talk about the waivers for a minute.  Seems like
a lot of waivers have been applied for and it seems to me that these
waivers are reasonable, to give an extension of time to let these
graduate medical students practice at other facilities so that they 
stay in the area.  Get DHS waivers so that these hospitals that are 
taking on DHS patients can get some reimbursements in the interim 
period.
There are some other kinds of waivers, say, for operating your hospital
at the Convention Center.  There is nothing wrong with the medical
care given there.  What is wrong is that it doesnï¿½t qualify as the 
standard of care because it doesnï¿½t have hard walls, right?  
Mr. Smithburg.  That is exactly right.  
Ms. DeGette.  It seems to me if you had the waivers already, you would 
have money coming into the system.  Right?  
Mr. Smithburg.  I think that is right.  To add a corollary, the 
Congress also has before it a bill that could have a Federal match to 
the Medicaid program that would affect all healthcare providers to 
help keep the doors open, and that has not been acted on at the time. 
As a result, our State has had to cut the Medicaid program at a time 
when we need it the most.  
Ms. DeGette.  So, you need waivers from HHS, from the Executive Branch,
but you also need Congress to act on legislation that would help with
Medicaid waivers, correct?  
Mr. Smithburg.  Yes.  
Ms. DeGette.  We are going back into session next week, Mr. Chairman, 
and I think one of our top priorities for congressional action should be 
this.  I hope we do that.
Well, if we canï¿½t get budget reconciliation, we need to put it in some 
other bill, a stand-alone bill.
I want to ask another question, because having toured your facilities, 
the old Charity Hospital and there is a University Hospital, and I think 
there is some consensus that the old Charity is a very dated facility 
and it may not just be worthwhile to use that as a medical facility, 
although it may be appropriate for something else.
How much of the delay you folks have had getting back up and running is
due to discussions about how do you reconfigure the way that you are 
delivering health care to the indigent, given the strange opportunity 
that you know you are having to start from scratch, recognizing this is 
more of a marathon than a sprint?  
Mr. Smithburg.  As it pertains to dealing with FEMA, the discussion has 
been more about logistics.  With regard to our future replacement and 
recognizing this is more of a marathon than a sprint, we do have a plan 
to replace ourselves and to replace ourselves with a smaller footprint.
If FEMA were to determine that Charity Hospital and University Hospital
were totaled, according to their recipe, we would theoretically be 
eligible for replacement dollars.  
Ms. DeGette.  FEMA is going to make that determination?  
Mr. Smithburg.  You know, we donï¿½t know.  We have been pressing very 
hard for the FEMA road map and they just now have agreed that they will 
begin to share with us their road map.
Again, I have visited with my friends in Houston and Southern California 
after the earthquake, and it was five years or more before any real 
resolution with FEMA was reached.  
Ms. DeGette.  You have got the temporary solution that you are going to 
open some emergency facilities through University Hospital.  Is that 
going to be a Level 1 trauma center?  
Mr. Smithburg.  Itï¿½s our hope to convert it into a small Level 1 trauma
center.  
Ms. DeGette.  How many patients will that be able to handle?  
Mr. Smithburg.  We have not gotten that far yet because we need to get 
deeper into the evaluation of the University, but we can tell you this: 
We are hoping to bring online about 200 beds.  Some of these will be
critical care beds, some of these will be bassinets.  But we donï¿½t 
really have the projections yet.  
Ms. DeGette.  When will you have those projections?
Mr. Smithburg.  I wish I knew the answer to that.  It takes a while, 
working with FEMA.  
Ms. DeGette.  Does FEMA have all the information from you folks 
they need to make these decisions?  Iï¿½m just trying to figure out what
the reason for this delay is.  
Mr. Smithburg.  I know we have provided them with really thousands
of pages of technical engineering reports and the like on the 
conditions of the building.  
Ms. DeGette.  When did you give them that information?  
Mr. Smithburg.  In November.  
Ms. DeGette.  And they have given you no indication of when you are
going to hear from them?  
Mr. Smithburg.  We are in active, regular dialogue with them, but 
timeframes and roadmaps have been difficult to acquire.  
Ms. DeGette.  I yield back my time.  
Mr. Whitfield.  Mrs. Blackburn, you are recognized for ten minutes.  
Mrs. Blackburn.  Thank you, Mr. Chairman.  I appreciate that.  Again, 
I thank all of you for your endurance this morning.
We have talked a lot about the reimbursement.  Mr. Smithburg, I know 
you would like to catch your breath, you have been talking endlessly. 
There are some other things we want on the record.  I am going to 
ask you all to endure with me because we have been making notes as
quickly as we can, as you have talked.
I want to focus on the operations end and move to that for just a
moment so that we have some of that information from you for the 
record.
One of the things we are tasked with, and the Chairman has touched 
on it, Mr. Stupak has touched on it, is looking at who is responsible 
for what, and beginning to clearly define and draw some bright white 
lines so that going forward, as we talk about what we have learned,
we figure out who is responsible for what and where decisions are 
to be made, where the responsibility lies.
So, this is what Iï¿½m going to do.  Iï¿½ll just read through this series 
of questions with you, and if you all make your notes and just 
respond per entity, that will be great.  I am going to ask you to do 
it as a written response, Iï¿½m not going to ask you to sit here and we 
will go down the line and do A, B and C.  I would like to have some 
thoughtful responses from you, because if we come in here and we say, 
the system is broke, itï¿½s a mess, Government is too bureaucratic, 
nobody can respond to this, da-da-da, then we donï¿½t make any progress.
Our goal should be very simple:  It should be to preserve access to 
healthcare for our constituents.  Our problem is how we get there.
So, I know that a lot of our rural hospitals have disaster plans that 
they go through to manage catastrophes, and I see that in my district 
in Tennessee.  Many times those are supplemented with guidelines from 
the AHA through a disaster readiness report.  I know that HCA has a
Disaster Readiness manual.  Mr. Muller, I think from--I have figured 
out from your testimony, you-all have a very complete one and I 
appreciate that.
I would like to know if each of your hospitals have a similar Disaster
Readiness manual, and in addition to just having the manual, do you 
have an implementation plan, because reading through the testimony, 
I think one of the things we are figuring out is that you have words
on paper, but you do not have a game plan for how to best get this 
into practice if it really happened; and do your plans include a
network of supporting hospitals to which you are going to turn?  Do 
each of the departments in your hospital have a copy of this?  Do 
they have team leaders, and do they have a chain of command?
And Mr. Muller, you referred to this and I appreciate that you did.  
Is there an operating chain of command so that they know who is in 
charge?  How often do you go through the process with your team?  
As you look at attrition and bringing in new people, how often are 
you talking with them about how to get it done?  How often do you 
practice these drills?  Are you giving lip service to it or are you 
putting your forces behind this to be certain that they understand 
that?
Letï¿½s talk about generators, because we had a lot of this in the 
testimony.  I was reading about all these generators and I did some 
digging getting ready for this hearing, and I come across a report, 
Hospital Security and Safety Management, December 1995, special 
report, "Recent Manmade and National Disasters, Testing the Hospitals
and Their Readiness."
In here, it talks about New Orleans and it talks about New Orleans 
getting 19 inches of rain in eight hours.  And it talks about the 
generators and the flooding.
Now, this was ï¿½95, so I want to know:  How were your generators--
when was the last time you had them tested; did you do as recommended 
and move them to upper floors, or were they still in the basement?  
Your potable water, the supply for that, was it in the basement or 
was it moved to an upper floor?
Your fuel supply for the generators, what were you looking at as your 
fuel supply for your generators?  What was your storage capacity, what
was the length of the expectation; and fuel supply, let me know if 
it is electric or if you are going to fuel, let me know what in your 
capacities are going to battery.  I would love to know that too.
The Louisiana State evacuation plan, how familiar you are with that?  
The plan states that hospitals have to put their generators and their
potable water on upper floors in order to obtain an operating permit.
So, are your permits up for review on a periodic basis?  When were
your operating permits last reviewed prior to Katrina, did your 
hospitals comply with the upper floor requirement of the plan and 
did the review examine this?  And if not, why not?
In order to make a decision--and the Chairman talked about this a 
little bit with your evacuation--I would love to know what your 
chain of command is for making a decision.  One of you is a parish
hospital and we have got public and we have got private.  What is 
that chain of command?  What is that readiness of availability of 
that chain of command during a time of emergency?
This is what I want to know:  If we gave you the pen and if you 
wrote the laws, what would you, if you were to write the rules, 
the regulations, and the laws, I would like to know what you 
would abolish.
Mr. Muller went through this in his testimony and I appreciate 
that.  Thatï¿½s the kind of information that is helpful to us.
Letï¿½s talk about communications.  Some of you mentioned the HAM 
radio worked for you, some of you had mentioned the cell phones 
and satellite phones did not.  We had a hearing on this in DC and
I know VoIP was used by a couple of people.  I would like for you 
to talk to us about your communications plan and where you are going 
to go with this.  How are you going to layer in these different 
technologies to be certain that you have a workable communications 
plan?
Mr. Chairman, I think that as our committee works on the communication
transition, and the analog spectrum becomes available, what we are 
hearing today is one of the reasons that the analog spectrum needed
to be made available for first responders and military, so that they
have that to work from.
Couple of things on supplies, because one of the consistent things 
in your testimony is that you had about four days of supplies, and 
having four days of backup and supplies, I would like to know if 
you-all have changed your procedure and if you are looking at having
a 7-day supply of your critical items.  Are you still working from 
a template that says four days of supplies?  I know that some of 
these folks last week in Mississippi were talking about they had
changed that and were looking at a 7-day supply.  So, I would like
to know, as a policy change, if you have made that as a change.
Also, on your supplies, we had most of the hospitals closed and a 
few open, so, if you were to have a surge of flu patients, as we 
talked about having facilities that are not Level 1 trauma 
facilities filling that need, and we talked about New Orleans 
coming back around, have you changed your plan so that you have 
emergency supplies in order to be able to accommodate that?  I 
think that is important.
One final question I have for with you, another article I found is
a 1999 article by Dr. Andrew Milstein on "Hospital Response to 
Acute Onset Disasters."  If you have not read it, I recommend that
each of you read it.  It is absolutely excellent.  One thing he 
points out on page 37 of this article, it is talking about Hurricane 
Camille.  I was a senior in high school when Hurricane Camille hit. 
I remember it very, very well.  It talks about Hurricane Hugo.  It
talks about since Hurricane Hugo, more deaths have occurred during
the post-impact period than during the impact phase.
I would think as healthcare professionals, this is something that 
we all need to be aware of, and that we would be hopeful that all 
of you are aware of.
With that, I will yield back my time, and again, I hate to give you 
homework, but I am so appreciative of you-all being here, of working
with us, and I hope that you accept this as our desire to be a partner 
with you, working through this as we address the healthcare.  I hope 
that we learn lessons from you that are applicable to each of our 
congressional districts, and that we spend that time together.
Mr. Chairman, I thank you.  
Mr. Whitfield.  Thank you.  I know you are going to be excited by 
answering these questions.  We may have some additional questions for 
you as well.
At this time, I recognize Ms. Schakowsky for ten minutes.  
Ms. Schakowsky.  Thank you.  Our witness that is coming on the second 
panel from HHS is going to testify that HHS has, at least as I 
understand it, issued all the waivers that are necessary for healthcare 
providers to continue to get reimbursements.  Seven pages of the 21-page
testimony are talking about all of the different waivers that have been 
put in place.  We talked about the 1115 waiver, 1135s. Has anybody 
received any of that money?
Let me ask you this:  I understand on November 10, Louisiana received
approval for the 1115 Medicaid waiver ensuring that certain Katrina 
victims will receive temporary enrollment in Medicaid through 
January 31, 2006.  Has the State received approval to extend this 
deadline?  All right.  Obviously that is an issue that we will have to
follow up on.
I wanted to ask about the potential for future problems.  Obviously, 
you want people to come here for Mardi Gras, we understand the economic
impact of that, but still, I want to ask: if the city of New Orleans 
is able to respond to another disaster, perhaps like another Katrina 
or a severe flu epidemic, or now the big Avian flu epidemic, or 
carnival, and so on, what is the plan?  Anyone who wants to answer?  
Ms. Fontenot.  I will be happy to speak to that.  I have been involved 
in that as well as with EMS providers.  I can tell you that as people
have stated before, we are in a healthcare crisis.  On any given day 
there are anywhere between 10 and 40 acute beds available, and that is
not just Orleans Parish, but Region 1, including Plaquemines, 
St. Bernard, Jefferson, and Orleans Parish.  So, we are one bus crash 
away from a major disaster, and I think the emergency room doctors 
that are at the institutions up and functioning will verify that.
We have been in planning with formal representation, but clearly we 
have limitations.  We are working together to establish a central
command and control for EMS for Orleans and Jefferson Parish, and there 
is a website that is good at updating, and we ask them to update those 
more rapidly because it has been a daily, so that EMS and Central 
Control and Command Center can access the web site to see where beds 
are available.  It is specific.  
Ms. Schakowsky.  Literally, it says here, thousands of beds at various 
locations.  Is that feasible or are any of these units available?  Have
you asked for them?  
Ms. Fontenot.  There have been--I know Dr. Guidry is on the next panel, 
and he may be able to give you more accurate and updated to information. 
We have asked for military assets.  And Iï¿½m not sure where those 
requests stand.  I am told that with the stretch already on the military
medical operations, those may not be forthcoming.  
Ms. Schakowsky.  Is he part of your planning unit?  
Ms. Fontenot.  He is the State Medical Officer and he always has a 
representative at the meeting.  
Ms. Schakowsky.  Now, sir, you stated that your hospital was the only
inpatient and emergency provider in St. Bernard Parish.  Despite the 
lack--there were 8,000 people back in St. Bernard and your facility 
remains closed.  Right?  
Mr. Sewell.  That is correct.  
Ms. Schakowsky.  Are you intending to reopen it?  
Mr. Sewell.  No decision has been made at this time.  They are still 
trying to ascertain the total amount of damage, but if a presence is 
rebuilt there, it will most likely involve razing the current hospital 
and constructing a totally new one.  
Ms. Schakowsky.  And in the meantime, who is supposed to provide medical
care for the citizens of St. Bernard Parish?  Is it spread around?  
Mr. Sewell.  There is a clinic operating, I believe FEMA is operating 
it, it is in a Wal-Mart parking lot.  I believe that is the only 
provider of care.  There are no inpatient providers.  
Ms. Schakowsky.  You stated, and I donï¿½t recall if you said in your
oral testimony, that as your medical staff, which was evacuated to 
the airport, along with 2,000 patients, your staff were not allowed by 
FEMA to provide care because they were not authorized, even though 
they are clearly licensed by the State of Louisiana.  So, credentialing 
of volunteer medical staff is a major issue.  What do we need to do 
about that?  
Mr. Sewell.  Iï¿½m not sure.  My heart went out to the gentleman who was
overseeing the MASH unit there, Dr. Ed Thornton from the Texas DMAT. 
He clearly was understaffed, and we had actually overheard him asking 
some other agency officials for some help, because they needed to 
move a lot of patients from one area to another and needed to change 
where they were staged.  We overheard him asking for help and then
offered him help.  He said to me at the time, "I need to inform you 
that you are not authorized to do this, but you know the drill:  We 
need your help and we will take what you can give us."
At that time, our staff attempted to do what we could to help them.  
They were tending to patients and mopping floors.  It was some time 
after that, that some other individual noticed we didnï¿½t have the 
correct shirts on or the right acronyms on the back, and informed 
us that we were not sanctioned to do that and asked us to move 
away.  
Ms. Schakowsky.  So you were asked to move away?  
Mr. Sewell.  Yes.  
Ms. Schakowsky.  That seems like an obvious thing to correct.
I want to address the mental health situation.  I donï¿½t know if 
anyone here is especially capable of answering that, but we all 
read about it and some of you may know of it personally, situations 
where people have committed suicide or are suffering from severe 
depression.  Can anybody describe the capabilities of addressing any 
mental health issues?  
Mr. Muller.  If I could, that was a pre-Katrina problem and is a much
more acute post-Katrina problem.  There are several areas.  It is a 
daily problem at every provider because we canï¿½t hold mental health 
patients because there are no available inpatient beds.  At the same 
time, the outpatient treatment can be done, but it slows down 
everything in the ED for the patients who can come in.  The good 
doctors get them outpatient treatment and give them meds.  
Ms. Schakowsky.  Speaking of medication, we have heard about problems 
with Medicare Part D around the country and availability of medication. 
Is that a problem?  Has it complicated the situation here?  
Mr. Muller.  It continues to be a problem.  The elderly are very 
confused.  We have a program at West Jeff that attempts to educate the
best we can every elderly patient that comes in to the hospital.  It 
is very, very confusing.
Now, with that being said, it is going to work eventually, probably, 
but it will be awhile.  
Ms. Schakowsky.  Mr. Montgomery, we were pleased to hear yesterday that
HCA will be opening by the end of February, or some services will.  Do 
you have an emergency room here in the central city?  Will your 
hospital be able to treat Medicaid and underinsured patients 
everywhere, or will they be sent elsewhere?  
Mr. Montgomery.  They will be treated here.  
Ms. Schakowsky.  I wanted to ask some more questions about
communications.  Again, I feel frustrated because--we are all 
frustrated,--but what kind of communication system should be 
established to work in case of such a disaster?  Can something be 
done rapidly as we approach the hurricane season again?  Are there 
steps being taken to get there right now and should it be 
interoperable between all respondents, not just hospitals, but 
police, fire, sheriff, and all the emergency facilities?  Are you
working on that now?  
Mr. Smithburg.  I will take a crack at it.  To be blunt, and this 
will probably come across as sounding a little self-serving, but we 
learned in Katrina that at the end of the day, you have to take care of
yourself, and take care of others if you can, but you have got to take 
care of those in your charge.  That, in fact, I think relates to 
communication.  While interoperability would be ideal, we have learned 
that HAM radio is something we are going to have to continue to invest 
in and grow that network, and that will be our fallback position.  That 
worked.  Again, it is slow.  The intermittentness of the police radios 
that we relied on is not sufficient if we have a catastrophe of that
level.  I am sure there are lots of solutions out there, but at the end 
of the day, at least in the near term, we have to focus on what we have 
to do for ourselves.  I hate to sound that way, but that is the way 
things are.  
Ms. Schakowsky.  Back to the future, huh?  HAM radios.
Thank you.  
Mr. Whitfield.  I want to thank this panel very much.  It has been truly 
enlightening.  We recognize there are several significant problems 
still out there, and I guess that is always the case when you are 
dealing with the local government, State governments and particularly 
with the complexity of our healthcare system.  I think we are going to
leave New Orleans, thanks to this panel, with certain clear 
understandings of precisely what the problems are here.  I think as 
everyone has indicated to you, we want to do everything we can to 
expedite the reopening of all of these facilities and continue to 
deliver effective healthcare in this area.
So I commend all of you and I thank you for your time and your
expertise and your commitment and enthusiasm.  With that, the first 
panel is dismissed and we will now call the second panel.
On the second panel today we have Dr. Jimmy Guidry, who is the 
Medical Director and State Health Officer for the Louisiana Department 
of Health and Hospitals, and we also have with us Dr. John Agwunobi, 
who is the Assistant Secretary of Health, United States Department of 
Health and Human Services.  
I want to remind you both, we are holding an investigative hearing.  
When doing so, it is our practice to take testimony under oath.  Do you 
have any objection to testifying under oath this morning?
I would advise you that under the rules of the House and the rules of 
the committee, you are entitled to be advised by legal counsel, and I 
would ask:  Do either of you desire to be advised by legal counsel
today?
So, if both of you would simply rise, and I would like to just swear 
you in at this time.  Raise your right hands.
[Witnesses sworn.]  
	Mr. Whitfield.  You are now sworn in.  Dr. Agwunobi, we will
	ask you to give your five-minute opening statement.

 TESTIMONY OF DR. JOHN O. AGWUNOBI, ASSISTANT SECRETARY OF HEALTH, 
 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; AND DR. JIMMY GUIDRY, 
 MEDICAL DIRECTOR AND STATE HEALTH OFFICER, LOUISIANA DEPARTMENT OF 
 HEALTH AND HOSPITALS
Dr. Agwunobi.  Thank you, sir.
Before I begin, I should probably state that prior to serving in this 
role, Assistant Secretary of Health and Human Services, I served as a
State Health Officer, a counterpart of Jimmyï¿½s, in the State of 
Florida.  And we went through a number of hurricanes, with 200 
hospitals as our responsibility.  I just want to say that the hospital
leaders of this community are absolutely outstanding, by all of the 
standards that I have seen out there, as a group and as individuals.  
They have seen their hospitals through some extremely, extremely tough 
times, and my hat is off to them.
Mr. Chairman and members of the subcommittee, Iï¿½m extremely happy to
be here.  
The past few months have been a very challenging time for HHS and the 
Nation as a whole, but we are proud of our efforts to date.  HHSï¿½s 
response to the hurricane disaster has been led from the very beginning
by Secretary Leavitt.  He has been extremely engaged and has been a
participant at each step of the way and in the affected areas, announced 
that he was making available the Departmentï¿½s full complement of 
emergency response assets and resources to States, hospitals, and 
citizens in general.  He has not held back.
On August 29, 2005, Hurricane Katrina struck the Gulf Coast just east of
New Orleans, near Gulfport, Mississippi.  The stormï¿½s impact was 
significantly increased by the failure of the levee around New Orleans on 
August 30.  On September 23, 2005, Hurricane Rita made landfall east of
Port Arthur, Texas.  The storms forced the evacuation of over 4 million 
people, destroyed tens of thousands of businesses and over 100,000 homes, 
forced the long-term relocation of over 685,000 families, destroyed at 
least eight hospitals, and were responsible for the deaths of over 1,200.
By comparison, the four Florida hurricanes of 2004 required the long-term 
relocation of 20,000 people and at the time set a record for that 
statistic.
HHS Secretary Mike Leavitt declared a public health emergency in the 
affected areas and announced he was making available the Departmentï¿½s 
full complement of emergency response assets and resources to States, 
municipalities, hospitals, and others in need of public health 
assistance for response to Hurricane Katrina.  The HHS operations 
center, which operates 24 hours a day, increased its staff and was in
constant communication with State and local emergency management 
operations, as well as other Federal departments.
Several of the agencies and the Department have responsibility for 
hurricane and disaster preparedness efforts.  To respond to this 
unprecedented natural disaster in our Nationï¿½s history, the Health 
Resources and Services Administration (HRSA), U.S. Public Health Service 
Commissioned Corps, and the Centers for Medicare and Medicaid Services 
(CMS) undertook extensive efforts, which I will discuss below.
During the hurricanes of 2005, several States were able to directly
and indirectly aid in the recovery and restoration of health and 
medical care to the most severely impacted Gulf States.  As a result of 
funds awarded through the HRSA National Bioterrorism Hospital 
Preparedness Program, North Carolina and Nevada provided on site mobile
medical facilities and associated medical teams, supplies, and equipment 
to support these facilities.  Other States that received large numbers
of evacuees, many with pre-existing health conditions that had gone
untreated for many days and weeks, were able to exercise surge plans, 
assemble and credential extra medical personnel, and have adequate 
supplies of medications and equipment ready to receive and treat 
evacuees.  Other States were able to donate communications equipment 
to the most severely impacted States to begin reestablishing 
communications with healthcare partners.
In the case of Katrina, HRSAï¿½s Emergency Systems for Advance 
Registration of Volunteer Health Provisions Program (ESAR-VHP) began 
working shortly after the hurricane made landfall.  This program worked 
with 21 States to provide as-needed assistance in the registration,
credential verification, and deployment of volunteer medical and 
healthcare professionals to the Gulf region.  Based on preliminary
figures, those 21 States reported sending over 8,300 pre-credentialed 
volunteer medical and healthcare providers to assist in the Katrina 
response.  To accomplish this, the ESAR-VHP program developed a 
temporary online registration and credential verification system that 
was used by seven States that had not yet started developing their 
ESAR-VHP systems.
Secondly, the program successfully negotiated with major physician and 
nurse credentialing organizations for free verification of volunteer 
credentials for the duration of the emergency.
Finally, the program assisted States in working with their Stateï¿½s 
emergency management agency to deploy health and medical personnel 
through the emergency management assistance compact in compliance with 
the national response plan.  Per requests from Louisiana, the HHS 
Office of the Surgeon General provided extensive support through the 
Commissioned Corps.  We supported a Secretaryï¿½s Emergency Response 
Team in Baton Rouge, with responsibility for all Emergency Support 
Function No. 8 incident leadership, command, operations, and 
logistics; provided assistance for environmental health support for
water, wastewater, sewer system, and food safety issues at schools,
child care centers, shelters, nursing homes, restaurants, pharmacies, 
and other retail establishments; supported FEMA and the Strategic
National Stockpile by coordinating distribution of pharmaceutical 
caches to response teams; staffed Special Needs Shelters across 
Louisiana to care for people who had been displaced from nursing 
homes, assisted living centers, and private homes during both 
Katrina and Rita.  These people were almost exclusively elderly, 
most had ambulation problems, many were on oxygen, and quite a few
required electronic device support to sustain life; staffed 3,550 
beds in Federal medical shelters that were established to receive 
special needs patients and lower acuity hospital patients in 
Louisiana; supported two animal rescue shelters in Louisiana; 
worked with Disaster Mortuary Operations Response Teams and Family
Assistance Centers in Louisiana to collect and identify the
deceased and trying to match grieving families with loved ones;
visited shelters throughout Louisiana to provide tetanus, 
influenza, and other common vaccines; and staffed the Surgeon 
Generalï¿½s Call Center, which recruited 34,000 plus civilian 
volunteers willing to deploy as nonpaid HHS employees.  As a 
result, more than 800 civilians were federalized and served in
Louisiana.
We formed public health teams to assess the health status of the 
population as well as the medical capacity of the impacted States,
provided mental health services in cooperation with the State 
Department of Education to reach 200,000 school children that were 
dealing with behavioral health issues related to the storm; 
evaluated a large number of hazardous waste, petroleum spills,
and chemical sites in the impacted States.
During this multi-State, multi-event response by over 2,500 
Commissioned Corps officers and 1,400 nonpaid HHS civilians, they 
distinguished themselves in hundreds of ways with their exceptional 
work to support the citizens of Mississippi, Louisiana, Texas, and
Florida.  The dedicated service of Corps officers in this deployment 
truly made an impact on the health status of the stricken people in 
the Gulf States.
The Centers for Medicare and Medicaid Services has acted to assure 
that the Medicare, Medicaid, State Childrenï¿½s Health Insurance
Programs and the Clinical Laboratory Improvement Amendments of 1988
have accommodated the emergency healthcare needs of beneficiaries and
medical providers in States directly affected by Hurricane Katrina this
year.  As part of the HHS effort to quickly aid beneficiaries and 
providers, Secretary Leavitt invoked time-limited statutory authority 
under Section 1135 (b) of the Social Security Act to permit CMS and its 
agents to waive or modify certain requirements or modify certain 
deadlines and timetables for the performance of required activities to
ensure that sufficient healthcare items and services are available.  
The 1135 waivers have and will continue to assist States directly 
affected by Hurricane Katrina and States hosting evacuees.
Furthermore, the Secretary authorized several Section 1115 
demonstrations, under which States may apply on a demonstration 
basis.  These demonstrations help States to provide coverage to 
evacuees from the affected geographic areas of Louisiana, Mississippi,
and Alabama, in which a natural disaster, consistent with the Stafford
Act, has been declared.
In addition, CMS temporarily relaxed and waived many of the policy and
billing requirements for hospitals and other providers to accommodate 
the emergency healthcare needs of beneficiaries and medical providers 
in the Hurricane Katrina-affected States.
Residents of the States affected by the hurricane and the providers in
all States that are assisting victims have faced extraordinary 
circumstances, and CMS fully supports the efforts of all providers to 
offer assistance.  Further, State agencies and their staff were an 
important and crucial part of the preparation and response and continue 
to be an intrinsic part of the recovery phases.  Hurricane Katrina 
demonstrated the importance of our partnership with State agencies as 
contacts for communications, advocates, links for resources, and 
facilitators for the provision of healthcare for all of those in need 
of care.
In partnership with States, CMS has acted to speed the provision of 
healthcare services to the elderly, children, and persons with 
disabilities by relaxing normal operating procedures until providers 
can reasonably be expected to continue under the normal requirements.  
The agency has been working closely with State medical agencies to 
coordinate resolution of interstate payment agreements for recipients 
who are served outside their home States.
CMS moved quickly to support efforts of the healthcare community.  The 
agency made short-term administrative adjustments to our Medicare and
Medicaid payment rules.  CMS implemented a flu Medicaid template waiver 
that provides for immediate, temporary and Medicaid coverage and 
financial support for medical services that fall outside of standard 
Medicaid benefits, all using existing systems in affected States to 
put them into service quickly and effectively.  In addition, CMS 
quickly established multiple strategies to communicate with affected
providers about the changes.  For instance, CMS posted question and 
answer documents on the CMS website; held special "open door forums" 
and arranged meetings with the affected States, national and State 
provider associations, and individual providers.
Mr. Chairman and members of the subcommittee, Hurricane Katrina caused 
severe devastation.  However, the network of compassion and caring 
demonstrated by Federal, State and local officials as well as healthcare
providers and others was a profound and powerful manifestation of the
greatness of this country.  Providers rushed to care for those in need 
without even considering payments or program requirements.  Providers 
who were personally affected by the hurricane as well as those in area
shelters and evacuees have provided extensive medical service under 
the most challenging conditions.  Our role is to support better efforts 
to care for seniors, people with a disability, children, and facilities 
with limited means and anyone else who needs care and has nowhere else 
to turn.
I want to assure you, Mr. Chairman and members, that HHS is actively 
focused on working with the affected communities.  HHS will continue
its efforts to work with hospitals and other facilities and ensure that 
they have adequate emergency plans in place should a disaster occur.  
And we are constantly reassessing the state of our preparedness for 
natural disasters as well as terrorist attacks and disease outbreaks, in 
order to ensure the best outcomes for our future.
I will stop there, and I will be happy to answer any questions. 
[The prepared statement of Dr. John O. Agwunobi follows:]
Prepared Statement of Dr. John O. Agwunobi, Assistant Secretary of
Health, U.S. Department of Health and Human Services

Mr. Chairman and Members of the Subcommittee, I am pleased to be here 
today to discuss the Department of Health and Human Services (HHS) 
emergency preparedness strategies.  The past few months have been a 
challenging time for HHS and our nation as a whole.  
On August 29, 2005, Hurricane Katrina struck the Gulf Coast just east
of New Orleans, near Gulfport, MS.  The stormï¿½s impact was significantly 
increased by the failure of the Lake Pontchatrain levee around New 
Orleans on August 30th.  On September 23, 2005 Hurricane Rita made
landfall east of Port Arthur, Texas.  The storms forced the evacuation 
of over 4 million people, destroyed tens of thousands of businesses, 
and over 100,000 homes, forced the long-term relocation of over 685,000 
families, destroyed at least 8 hospitals, and were responsible for the
deaths of over 1,200 people.  By comparison, the four Florida hurricanes
of 2004 required the long-term relocation of 20,000 people, and at the 
time, set a record for that statistic.  

HHS Response to Hurricane Disasters
HHS Secretary Mike Leavitt declared public health emergencies in the 
affected areas and announced he was making available the Departmentï¿½s 
full complement of emergency response assets and resources to states, 
municipalities, hospitals and others in need of public health assistance 
for response to Hurricane Katrina.  The HHS Operations Center, which 
operates 24 hours a day, increased its staff and was in constant 
communication with state and local emergency management operations, as 
well as other federal departments.
Several of the Agencies within the Department have responsibility for 
hurricane and disaster preparedness efforts.  To respond to this 
unprecedented natural disaster in our nationï¿½s history, the Health 
Resources and Services Administration (HRSA), US Public Health Service 
Commissioned Corps, and the Centers for Medicare & Medicaid Services 
(CMS) undertook extensive efforts, which I will discuss below.  

Health Resources and Services Administration Response
During the hurricanes of 2005, several states were able to directly 
and indirectly aid in the recovery and restoration of health and 
medical care to the most severely impacted Gulf States. ï¿½As a result
of funds awarded through the HRSA National Bioterrorism Hospital 
Preparedness Program, North Carolina and Nevada provided on-site 
mobile medical facilities and associated medical teams, supplies and
equipment to support these facilities. ï¿½Other states that received 
large numbers of evacuees, many with pre-existing health conditions 
that had gone untreated for many days and weeks, were able to exercise
surge plans, assemble and credential extra medical personnel and have 
adequate supplies of medications and equipment ready to receive and
treat evacuees. ï¿½Other states were able to donate communications 
equipment to the most severely impacted states to begin re-establishing 
communications with healthcare partners.
ï¿½In the case of Katrina, HRSAï¿½s Emergency Systems for Advance 
ï¿½Registration of Volunteer Health Professionals (ESAR-VHP) program 
ï¿½began working shortly after the hurricane made landfall.ï¿½ The 
ï¿½ESAR-VHP program worked with 21 states to provide "as-needed" 
ï¿½assistance in the registration, credential verification, and 
ï¿½deployment of volunteer medical and healthcare professionals to the 
ï¿½Gulf region.ï¿½ Based on preliminary figures, these 21 states reported 
ï¿½sending over 8,300 pre-credentialed volunteer medical and healthcare
ï¿½providers to assist in the Katrina response.ï¿½ To accomplish this, 
ï¿½the ESAR-VHP program developed a temporary on-line registration and 
ï¿½credential verification system that was used by seven states that 
ï¿½had not yet started developing their ESAR-VHP systems.ï¿½ 
ï¿½Secondly,ï¿½the program successfully negotiated with major physician 
ï¿½and nurse credentialing organizations for free verification of 
ï¿½volunteer credentials for the duration of the emergency. 
ï¿½Finally, the program assisted States in working with their 
ï¿½State's emergency management agency to deploy health and 
ï¿½medical personnel through the Emergency Management Assistance 
ï¿½Compact in compliance with the National Response Plan. Per requests 
ï¿½from Louisiana, the HHS Office of the Surgeon General provided 
ï¿½extensive support through the Commissioned Corps (CC):
Supported a Secretaryï¿½s Emergency Response Team (SERT) in Baton 
Rouge, with responsibility for all Emergency Support Function No. 8 
incident leadership, command, operations, and logistics.
Provided assistance for environmental health support for water, 
wastewater, sewer system, and food safety issues at schools, childcare
centers, shelters, nursing homes, restaurants, pharmacies, and other 
retail establishments.
Supported FEMA and the Strategic National Stockpile by coordinating 
the distribution of pharmaceutical caches to response teams.
Staffed Special Needs Shelters across Louisiana to care for people who 
had been displaced from nursing homes, assisted living centers and 
private homes during both Katrina and Rita.  These people were almost
exclusively elderly, most had ambulation problems, many were on oxygen, 
and quite a few required electronic device support to sustain life.
Staffed 3,550 beds in Federal Medical Shelters that were established 
to receive special needs patients and lower acuity hospital patients 
in Louisiana.
Supported two animal rescue shelters in Louisiana.
Worked with Disaster Mortuary Operations Response Teams and Family 
Assistance Centers in Louisiana to collect and identify the deceased 
and trying to match grieving families with loved ones.
Visited shelters throughout Louisiana to provide tetanus, influenza,
and other common vaccines.
Staffed the Surgeon Generalï¿½s Call Center which recruited 34,000 + 
civilian volunteers 0willing to deploy as non-paid HHS employees.  As a 
result, more than 800 civilians were federalized and served in Louisiana.
Formed public health teams to assess the health status of the population
as well as the medical capacity of the impacted states.
Provided mental health services in cooperation with the State Department 
of Education, to reach 200,000 school children that were dealing with the
behavioral health issues related to the storms.
Evaluated a large number of hazardous waste, petroleum spills, and 
chemical sites in the impacted states.
During this multi-state, multi-event response by over 2,500 Commissioned 
Corps officers, and 1,400 non-paid HHS civilians, they distinguished 
themselves in hundreds of ways with their exceptional work to support the
citizens of Mississippi, Louisiana, Texas, and Florida.  The dedicated 
service of Corps officers in this deployment truly made an impact on the 
health status of the stricken people of the Gulf States.  

Centers for Medicare & Medicaid Services Hurricane Disaster Efforts 
The Centers for Medicare & Medicaid Services (CMS) has acted to assure 
that the Medicare, Medicaid, State Childrenï¿½s Health Insurance Programs, 
and the Clinical Laboratory Improvement Amendments of 1988 (CLIA) have 
accommodated the emergency health care needs of beneficiaries and medical 
providers in states directly affected by Hurricane Katrina this year. 
As part of the HHS effort to quickly aid beneficiaries and providers, 
Secretary Leavitt invoked time-limited statutory authority under section
1135(b) of the Social Security Act to permit CMS (and its agents) to 
waive or modify certain requirements, or modify certain deadlines and 
timetables for the performance of required activities, to ensure that 
sufficient health care items and services are available.  The 1135 waivers 
have and will continue to assist states directly affected by Hurricane 
Katrina and states hosting evacuees.  Furthermore, the Secretary 
authorized several section 1115 demonstrations, under which states may 
apply on a demonstration basis.  These demonstrations help States to
provide coverage to evacuees from the affected geographic areas of 
Louisiana, Mississippi, and Alabama,  in which a Natural Disaster, 
consistent with the Stafford Act, has been declared.  
In addition, CMS temporarily relaxed and waived many of the policy and 
billing requirements for hospitals and other providers to accommodate
the emergency health care needs of beneficiaries and medical providers
in the Hurricane Katrina affected states.
Residents of the states affected by the hurricane, and the providers in 
all states that are assisting victims have faced extraordinary 
circumstances and CMS fully supports the efforts of all providers to offer
assistance.  Further, state agencies and their staff were an important and 
crucial part of the preparation and response and continue to be an intrinsic
part of the recovery phases.  Hurricane Katrina demonstrated the importance
of our partnership with state agencies as contacts for communications,
advocates/links for resources, and facilitators for the provision of health
care for all of those in need of care.  
In partnership with states, CMS has acted to speed the provision of health 
care services to the elderly, children, and persons with disabilities by 
relaxing normal operating procedures until providers can reasonably be 
expected to continue under the normal requirements.  The Agency has been 
working closely with state Medicaid agencies to coordinate resolution of 
interstate payment agreements for recipients who are served outside their 
home states.
CMS moved quickly to support efforts of the health care community.  The 
Agency made short-term administrative adjustments to our Medicare and 
Medicaid payment rules.  CMS implemented a new Medicaid template waiver 
that provides for immediate, temporary Medicaid coverage and financial 
support for medical services that fall outside of standard Medicaid
benefits, all using existing systems in affected states to put them into
service quickly and effectively.  In addition, CMS quickly established 
multiple strategies to communicate with affected providers about the
changes. For instance, CMS posted question and answer documents on the 
CMS website; held special "Open Door Forums;" and arranged meetings 
with the affected states, national and state provider associations, 
and individual providers.  

CMS Requirements for Emergency Situations
CMS works with a number of different entities, including state government
agencies, professional associations, and contractors to ensure that
entities receiving Medicare and Medicaid payments comply with 
established requirements for their provider type.  These requirements 
are referred to as Conditions of Participation (CoPs) and Conditions 
for Coverage (CfCs).  Besides requiring that providers have policies 
and procedures in place to ensure quality of patient care, these 
conditions also require that providers are adequately prepared to
continue treating patients if an emergency situation occurs.
These conditions, which may reference other consensus standards such 
as the National Fire Protection Association codes, require organizations
to have emergency contingency plans in place, for which requirements
vary by provider type.  CMS uses state health agencies and accrediting
organizations to determine whether health care providers and suppliers 
meet Federal standards.  CMS also ensures that the standards of 
accrediting organizations recognized by CMS (through a process called 
"deeming") meet or exceed Medicare standards.  

Regulations and guidance for hospitals
Hospitals are required to comply with CMS conditions of participation.
As such, the hospitals must develop and implement a comprehensive plan
to ensure that the safety and well-being of patients are assured 
during emergency situations.  The hospital must coordinate with 
Federal, State, and local emergency preparedness and health authorities
to identify likely risks for their area (e.g., natural disasters; 
bioterrorism threats; disruption of utilities such as water, sewer, 
electrical communications, and fuel; nuclear accidents; industrial 
accidents; and other potential mass casualties) and to develop 
appropriate responses that will assure the safety and well-being of 
patients.  Further, there must be emergency power and lighting in at 
least the operating, recovery, intensive care, and emergency rooms, 
and stairwells.  In all other areas not serviced by the emergency 
supply source, battery lamps and flashlights must be available.  Also,
there must be facilities for emergency gas and water supply; however, 
there is no duration specified for the fuel supply.
In an emergency, CMS defers to State and local governments to consider 
issues such as the special needs of patient populations treated at 
the hospital (e.g., patients with psychiatric diagnosis, patients on
special diets, or newborns); pharmaceuticals, food, other supplies and 
equipment that may be needed during emergency/disaster situations;
communication to external entities if telephones and computers are not 
operating or become overloaded (e.g., use of satellite (cell) phones to 
reach community officials or other healthcare facilities if transfer of 
patients is necessary); and transfer or discharge of patients to home, 
other health care settings, shelters, or other hospitals.

CMS Conducts Oversight of Hospital Compliance
In addition to the regulations outlining the emergency preparedness 
requirements for all Medicare and Medicaid providers, CMS has multiple 
oversight functions in place to ensure that facilities adhere to the 
Agencyï¿½s standards of operation.  CMS maintains oversight for compliance 
with the Medicare health and safety standards for hospitals serving 
Medicare and Medicaid beneficiaries, and makes available to 
beneficiaries, providers/suppliers, researchers and State surveyors 
information about these activities.  
The survey (inspection) for this determination is done on behalf of 
CMS by the individual State Survey Agencies.  

CMS Accommodated Emergency Health Care Needs After Hurricane Katrina
CMS has acted to assure that the Medicare, Medicaid and State 
Childrenï¿½s Health Insurance Programs were flexible to accommodate the
emergency health care needs of beneficiaries and medical providers in 
the Hurricane Katrina devastated states.  More specifically, many of 
the Medicare fee-for-service programï¿½s normal operating procedures were 
temporarily relaxed to speed provision of health care services to the 
elderly, children and persons with disabilities who depend upon them.

CMS Worked to Expand Availability of Inpatient Beds
To expand the availability of inpatient beds and ensure that patients 
have access to needed inpatient care, CMS waived many of Medicareï¿½s
classification requirements, allowing specialized facilities and
hospital units to treat patients needing inpatient care.  For example, 
CMS did not count any bed use that exceeds the 25-bed or 96-hour average
length of stay limits for critical access hospitals (CAHs) located in 
the public health emergency states if such use was related to the 
hurricane.  
CMS did not count admissions to inpatient rehabilitation facilities 
(IRFs) located in the public health emergency states toward compliance
with the 75 percent rule if such admissions were related to the 
hurricane.  
CMS did not count patients admitted to a long-term care hospital (LTCH) 
located in the public health emergency states toward the calculation 
of the facilityï¿½s average length of stay if such admissions were
related to the hurricane.  
CMS allowed beds in a distinct psychiatric unit in an acute care 
hospital located in the public health emergency states to be available 
for patients needing inpatient acute care services if such use was 
related to the hurricane.  

CMS Relaxed Medicare Billing Requirements and Accelerated Payments 
To accommodate the emergency health care needs of beneficiaries, CMS 
temporarily relaxed Medicare billing requirements and offered 
accelerated payment options for providers furnishing such care.  For 
example, 
CMS allowed hospitals to have a responsible physician at the hospital 
(e.g., chief of medical staff or department head) to sign an 
attestation when the attending physician could not be located.  
CMS allowed providers affected by the hurricane to file paper claims 
if necessary.
CMS instructed its contractors to facilitate the processing of claims 
for services furnished by physicians to treat patients outside the
normal settings (e.g., shelters).
CMS paid the inpatient acute care rate and any cost outliers for 
Medicare patients that no longer needed acute level care but remained 
in a hospital located in the public health emergency states until the 
patient could be moved to an appropriate facility.
For those teaching hospitals that were training residents that were 
displaced by the hurricane, CMS temporarily adjusted the hospitalï¿½s 
full-time equivalent cap on residents, as needed, to allow the 
hospital to receive indirect or direct graduate medical education 
payments for those displaced residents.  The temporary adjustment 
applied as long as the original program in which the displaced resident 
trained remained closed.  
Accelerated or advance payments were available to those providers who 
were still rendering some services or were taking steps to be able to 
furnish services again, despite having their practice or business 
affected or destroyed by the hurricane.  
CMS instructed its contractors to process immediately any requests for 
accelerated payments or increases in periodic interim payments for 
providers affected by the hurricane.  
The intermediaries also were instructed to increase the rate of the 
accelerated payment to 100 percent and extend the repayment period to 
180 days on a case-by-case basis.  
CMS instructed its intermediaries to approve requests for extensions 
to cost report filing deadlines for providers affected by the 
hurricane.  
The intermediaries also were instructed to accept other data they 
determined are adequate to substantiate payment to the provider when 
a facilityï¿½s records were destroyed.  This determination was done on 
a case-by-case basis.  
CMS allowed providers who waived the coinsurance and deductible amounts
for indigent patients affected by the hurricane to claim bad debt, even
in cases where documentation regarding a patientï¿½s indigence was
unavailable.  Providers were required to note their observations or
submit any documentation they could along with a brief signed statement
by medical personnel regarding the patientï¿½s indigence.  

CMS Assistance Available for Rebuilding Health Care Infrastructure
CMS - Medicare Extraordinary Circumstances Exception Provision
The Medicare inpatient prospective payment system includes payment for 
hospital inpatient capital costs, which is made on a per-discharge 
basis.  The extraordinary circumstances exception provision provides an 
additional payment if a hospital incurs unanticipated capital 
expenditures in excess of $5 million (net of proceeds from other funding 
sources, including insurance, litigation, and government funding such as
FEMA aid) due to extraordinary circumstances beyond the hospitalï¿½s control
(e.g., a flood, fire, or earthquake).  
For most hospitals, the exception payments for extraordinary circumstances
are based on 85 percent of Medicareï¿½s share of allowable capital costs 
(100 percent for sole-community hospitals) attributed to the extraordinary
circumstance.  The payments are made for the annualized portion of the 
extraordinary circumstance costs, over the useful lifetime of the assets, 
not in a lump sum.  A hospital must make an initial written request to its
CMS Regional Office (RO) within 180 days after the occurrence of the 
extraordinary circumstance causing the unanticipated expenditures.  

CMS Makes Available Waiver of the Physician Self-Referral Law for Limited
Cases
In response to the recent hurricane, CMS has received inquiries concerning 
whether hospitals can provide free office space, or low interest or no 
interest loans, or offer certain arrangements to physicians who have been 
displaced by the hurricane.  The Secretary has given CMS authority to 
waive sanctions for violations of the physician self-referral (Stark) law
(which prohibits physicians from referring Medicare patients to an entity 
with which the physician or a member of the physicianï¿½s immediate family
has a financial relationship, unless the arrangement meets the criteria
of one of the statutory or regulatory exceptions).  The States in which 
the Stark waiver is available are limited to those States that have 
received a Section 1135 waiver due to Hurricane Katrina.
CMS is considering Stark waiver requests on a case-by-case basis and/or
through guidance posted on the CMS website, and is waiving Stark 
violations in such circumstances as CMS determines appropriate.  The 
focus is to ensure access to care and to assist displaced physicians in 
the affected areas.  CMS is temporarily allowing arrangements that
otherwise would not meet the specific criteria for an exception, provided
that such arrangements do not lead to program or patient abuse, and that 
other safeguards which may be applicable to the specific arrangement 
under consideration exist.  
The Role of Section 1115 Demonstrations
In an effort to ensure the continuity of health care services for the 
victims of Hurricane Katrina, CMS developed a new section 1115 
demonstration initiative.  Under this program, States were able to apply 
to be part of a unique cooperative demonstration that allows Medicaid 
and State Childrenï¿½s Health Insurance coverage of evacuees from the 
affected geographic areas of Louisiana, Mississippi, and Alabama.  Under
this demonstration, effective retroactively to August 24, 2005, evacuees
who were displaced from their homes as a result of Hurricane Katrina 
were provided the opportunity to enroll to receive services under the 
Medicaid or SCHIP programs in whatever State they now reside so long as 
the host state applied for a Katrina demonstration.  The host states
are allowed to provide their stateï¿½s Medicaid/SCHIP benefit package and
comprehensive State Plan services to evacuees, who can receive this 
coverage for up to 5 months.  Evacuees apply through a simplified 
application within the Host State through January 31, 2006.  This 
demonstration allows for self-attestation for items such as 
displacement, income, residency, resources, and immigration status if 
the evacuee is unable to provide documentation. There is no obligation
on the Host State to redetermine eligibility for evacuees at the end
of this period.  States are encouraged to assist individuals in 
applying for assistance in the State in which they are currently 
residing.  
States that have been authorized 1115 demonstration authority include 
Alabama, Arkansas, California, the District of Columbia, Florida, 
Georgia, Idaho, Indiana, Louisiana, Maryland, Mississippi, Nevada, 
Ohio, South Carolina, Tennessee, Texas and Puerto Rico.  
CMS reviewed and approved waivers for states housing the vast majority 
of evacuees, and is now providing immediate, comprehensive relief for 
evacuees who have left their home state, regardless of whether they 
had previously been determined eligible for Medicaid in their home 
state, or they are newly eligible for Medicaid due to loss of income 
and resources as a result of Hurricane Katrina.  
This demonstration initiative permits Host States to offer Medicaid 
and SCHIP benefits to parents, pregnant women, children under age 19,
individuals with disabilities, low-income Medicare recipients, and 
low-income individuals in need of long-term care within certain income 
parameters using a simplified eligibility chart or the eligibility 
levels from the affected States.  As an evacuee, an individual is 
required to attest that he/she is displaced from certain geographic 
regions and to cooperate in demonstrating evacuee status.  
Uncompensated Care Pools
CMS approved uncompensated care pools in several states.  The 
uncompensated care pool allows States to reimburse providers that 
incur uncompensated care costs for medically necessary services and 
supplies for Katrina evacuees who do not have other coverage for such 
services and supplies through insurance, or other relief options 
available including Medicaid and SCHIP for a 5 month period effective 
from August 24, 2005, through January 21, 2006.  The pool may also be 
used to provide reimbursement for benefits not covered under Medicaid 
and SCHIP in the states.  These uncompensated care pools cannot be used 
to reimburse providers for uncompensated care costs beyond January 31, 
2006 or for services provided to Medicaid and SCHIP eligibles in the 
host state.

The Role of 1135 Waivers
Section 1135 of the Social Security Act allows the Secretary of Health 
and Human Services to waive or modify certain Medicare, Medicaid, or 
SCHIP requirements to protect the public health and welfare in times of 
national crisis.  
On August 27, 2005, President Bush made a disaster declaration in 
response to Hurricane Katrina.  On Wednesday August 31, 2005 Secretary 
Leavitt notified the Congress that he was invoking his waiver authority, 
as a consequence of Hurricane Katrina, in order to protect the health 
and welfare of the public in areas impacted by this crisis.  CMS is 
taking action consistent with this authority to ensure that the people 
in these areas receive all necessary health care services.  
In his declaration, the Secretary specified that a public health 
emergency existed since August 24, 2005 in the State of Florida and 
since August 29, 2005 in the States of Alabama, Louisiana, and 
Mississippi.  Declaring a public health emergency enabled the Secretary
to authorize waivers to states in order to facilitate the provision of
health care services.  He began authorizing 1135 waivers on 
September 4, 2005, which became effective on September 6, 2005, but
were effective retroactively to August 24, 2005 in Florida; August 29, 
2005 in Alabama, Louisiana, and Mississippi; and September 2, 2005 in 
Texas.  CMS approved waivers in other states that were directly affected
by Hurricane Katrina or hosted evacuees, including Arkansas, Colorado, 
Georgia, North Carolina, Oklahoma, Tennessee, West Virginia, and Utah.  
By issuing 1135 waivers to states affected by Hurricane Katrina, there
was increased flexibility for providers and beneficiaries.  The waivers
flexed the normal eligibility and enrollment requirements used to apply 
for Federal benefits so that no one who has been a victim of the 
hurricane would be prevented from getting benefits.  For instance, CMS 
recognized that many evacuees lost all identification and records, so 
the Agency gave states the flexibility to enroll people without 
requiring the usual documents such as tax returns or proof of 
residency.  In addition, requirements were temporarily relaxed for 

certain conditions of participation, certification requirements, 
program participation or similar requirements, or pre-approval
requirements for individual health care providers or types of health
care providers, including as applicable, a hospital or other provider 
of services, a physician or other health care practitioner or
professional, a health care facility, or a supplier of health care items
or services;
the requirement that physicians and other health care professionals hold 
licenses in the State in which they provide services, if they have a
license from another State (and are not affirmatively barred from 
practice in that State or any State in the emergency area); 
sanctions under the Emergency Medical Treatment and Labor Act, or
EMTALA, for the redirection of individuals to receive a medical 
screening examination or transfer;
permitting Medicare Advantage enrollees to use out-of-network 
providers; and,
sanctions and penalties arising from noncompliance with certain 
provisions of the HIPAA privacy regulations including the requirements 
to obtain a patientï¿½s agreement to speak with family members or friends
or to honor a patientï¿½s request to opt out of the facility directory.
Through these efforts, evacuees are getting the care they need so they 
can get back on their feet.  CMS is making sure that the health care 
community is reimbursed for providing that care.  Further, the Agency 
is making sure that states hosting evacuees are covered for any
substantial expenses that they incur.  

Conclusion
Mr. Chairman and Members of the Subcommittee, Hurricane Katrina caused 
severe devastation.  However, the network of compassion and caring 
demonstrated by federal, state, and local officials, as well as health 
care providers and others was a profound and powerful manifestation of 
the greatness of this country.  
Providers rushed to care for those in need without even considering 
payments or program requirements.  Providers, who were personally 
affected by the hurricane, as well as those in areas sheltering 
evacuees, have provided extensive medical services under the most 
challenging conditions.  Our role is to support their best efforts to 
care for seniors, people with a disability, children and families with 
limited means, and anyone else who needs care and has nowhere else to 
turn.  
I want to assure you, Mr. Chairman and Members, that HHS is actively 
focused on working with the affected communities.  HHS will continue 
its efforts to work with hospitals and other facilities and ensure 
they have adequate emergency plans in place should a disaster occur.  
And we are constantly reassessing the state of our preparedness for 
natural disasters, as well as terrorist attacks and disease outbreaks,
in order to ensure the best outcomes for our future. 
This concludes my testimony.  I will be happy to answer any questions.  

Mr. Whitfield.  Thank you.
Dr. Guidry, you are recognized for five minutes for your opening 
statement.
Dr. Guidry.  Thank you very much, Mr. Chairman and committee members, 
for giving us this opportunity.
I must tell you that we certainly want to spend the time doing this so 
that we can move to lessons learned and certainly intend to see what we 
have been through.
I think the disaster is not the correct word for what occurred here, 
catastrophe is.  Everybody has been planning and preparing for 
disasters, which is in the short term, but every day I hear, "We have
never done this before, we have never done this before."
So I think that pretty much tells it.  What I thought I would do with 
my five minutes is try and move very quickly through some of the things 
that were successful, that have not made the media, that very few 
people are aware of.
Pre-storm, we established a department of triage lines to help those 
people evacuate and help make their decisions about leaving their 
families and reporting to special needs shelters as a last resort or
seeking care and sheltering in area hospitals.  We evacuated from this
affected area some 1.3 million people, which I think is phenomenal, to
move that many people from the highway and off the highway to shelters 
and hotels.
We accepted 150 special needs evacuees in Baton Rouge from the 
Superdome prior to the storm, and staff from the city of New Orleans 
opened a section of the Superdome for special needs evacuees.  It is 
critical that we explain that with the hospitalsï¿½ ability to take care 
of sick people being downsized and the number of people that are 
becoming elderly (inaudible) the specialty population is growing at an 
alarming rate.
The Department of Social Services (inaudible) we cared for some 1,200 
special need evacuees pre-storm and worked with the Nursing Home 
Association to evacuate 19 nursing homes prior to the storm.  We 
worked with the hospital association to assist hospitals and evacuate 
patients that were able to travel.  We worked with CMS to try to 
assist with some of this (inaudible) for transportation that was 
overwhelmed.
Post-storm we sent a Federal DMAT team into the Superdome to help 
(inaudible) did special need sheltering at Nicholls State and
established temporary MedEvac staging areas.  This I think is a
critical piece (inaudible).
We opened up an assembly center with 400 beds, initially wrapped up 
with 800 true emergency room beds.  Never been (inaudible) through 
this country.  Over 40,000 of those evacuees were triaged to that 
facility, and on the Nicholls campus, over 20,000.  I think what we 
have a hard time understanding is that not only the damage but the
volume (inaudible) not of saving lives when there is total chaos and 
disaster.
  We worked with NOMS to create a Medicare program at the Kenner airport,
  where we sent 180 hospital patients out of State.  Keep in mind, that 
  system had never been used in the history of this country, so, 
  obviously, there were some issues there as we moved people out of this
  affected area.  We sent EMS teams to search and rescue, and had a base 
  of operations there at the Causeway because that was above water.  We 
  worked with the Nursing Home Association and evacuated another 
  34 nursing homes post-storm.  Hospital Association evacuated 
  25 hospitals, 12,000 patients and caregivers, as you heard this 
  morning, heroic efforts by anybodyï¿½s measurements.  We evacuated 
  120 premature and newborn babies from New Orleans hospitals to Baton
  Rouge Womenï¿½s Hospital, and provided immunization and pharmaceuticals 
  provided to evacuees at shelters with the help of public health.  We 
  gave over 110,000 vaccinations (inaudible) and coordinated (inaudible) 
  medical volunteers.
You heard this morning there was a credentialing issues.  There are 
issues when you try to work with the Federal team as to whether you are
allowed to do that.  We worked with DMAT to (inaudible) in Rita, which
a lot of us have not talked about this morning, which was right on the
heels of Katrina, we then moved all people who had been moved to the
west side of the State, up north, back to the east side.  So, again,
special needs shelters in Lafayette were closed and those patients were 
moved to Shreveport and Monroe.
 Special needs shelters in Baton Rouge increased their capacity to 
 receive these evacuees.  We then opened school gymnasiums so nursing 
 homes could bring in their (inaudible) assisted nursing homes could 
 not handle anymore.  There were 19 hospitals evacuated (inaudible) 
 medical needs (inaudible).
What Iï¿½m afraid of is this next hurricane season, as we develop our 
plans, we are going to rely on some assets we used in Rita that were 
very successful.  We didnï¿½t lose people in Rita.  Those assets were 
here because Katrina had occurred.  The fear is that (inaudible) and
we had a lot of assets we wouldnï¿½t normally have, so when you get this 
next hurricane season, people think these assets will be readily 
available again, and I think the planning will fall way short.
Post-Rita, we reopened special needs shelters temporarily in Lafayette 
and received those Katrina evacuees back into the area.  We opened a 
temporary medical staging area at one of the hospitals in Lake 
Charles.  We also opened a base of operations at the Convention Center
in Lake Charles.  We assisted with hospitals by sending (inaudible) to
shelters that would take patients that were too sick (inaudible) and 
sent back to us.  We worked with DMAT to address surge.  There were 
some 600 needs (inaudible).
We had met several times with the Louisiana Recovery Authority and
healthcare reform groups to talk about what they could do to help us 
and what they need to look at.  I would like to go into detail with 
some things that we have to look at in the upcoming season and long 
term.
Some of the things we talked about was how to incentivize, making sure
we can take care of peopleï¿½s healthcare needs in a State that is one 
of the poorest in the country, with the most healthcare needs.  As you
heard today, the hospitals and emergency rooms are critical because 
our patients (inaudible) preventing healthcare.
So, we talked to groups about how they can help us with that.  Because
of the shortness of time, Iï¿½m going to go directly to some of the
recommendations I see as critical.  HRSA grants, really since 9/11, 
have made a difference in hospital preparedness.  They literally were
islands until themselves until these grants forged the networks we had
in the State which at its regional level, each State has come to the 
table, and how do they help those around the State?  So, these grants 
havenï¿½t been discussed as possibly diminishing in the future.  I can
tell you without those grants, I would not have saved so many lives.  
It would not have happened, because a lot of this manning and 
preparation occurs as a result of those grants.
The Stafford Act, if I heard it one more time--it is just, you know, 
it does not address healthcare.  It does not take care of healthcare,
so when FEMA comes in, it will help take care of what our needs are, 
but healthcare needs, as you all heard this morning, are not being
met.  Unless we make the Stafford Act apply to healthcare or we have
the healthcare act address catastrophes, we see (inaudible) and how 
do we address that for the long term?  Nobodyï¿½s gone beyond a week or 
two weeks in addressing healthcare needs (inaudible).
Money for purchasing generators and special needs shelters.  I opened
special needs shelters (inaudible) which were all at risk of being 
flooded, taking care of patients that need care.  I have asked for 
generators for ten years.  I have asked the State, I have asked the 
Federal.  They are very expensive.  We are talking about anywhere
from $700,000 to $1 million for generators.  We put in switches to get 
the generators in, we asked the State for them.  There were some in 
Florida.  We did not get those.  (Inaudible).  We brought some in from
Illinois.  They brought the generators in, but they did not have the
connections.  So, these generators were not even able to be used.
Then, as you heard about the hospital generators, we have asked for
mitigation funds for this.  People say, well--knowing this could 
happen--I said yes, and no one stepped up to the plate to help us 
figure out to do this financially.  And I said, "Now we have had the
biggest disaster in the country and no one stepped up to the plate to 
figure out hot to do a generator."
So to say that, "Did you ask for it, thatï¿½s not the question.  The 
question is, "When you do ask for it, do people think it is a critical 
need?"  We are all getting older and we are all going to be dependent
on power to (inaudible).  It is a life-saving measure.
So, thatï¿½s a quick summary of what I have to say.  Iï¿½m sure you have 
a lot of questions and I really am proud to be here and that you came
to see this.  I think part of the issue has to be that you-all 
realize the magnitude. 
[The prepared statement of Dr. Jimmy Guidry follows:]
Prepared Statement of Dr. Jimmy Guidry, Medical Director and State 
Health Officer, Louisiana Department of Health & Hospitals

Summary of accomplishments by DHH and Partners:  
Hurricane Katrina:
PRE-STORM:
Established Triage lines to assist special needs evacuees to make 
decisions about leaving with their families, reporting to special 
needs shelters as a last resort or seeking shelter or care at 
hospitals.
Accepted 150 special needs evacuees in Baton Rouge from the Superdome 
prior to storm.
Assisted with equipment and staffing to City of Orleans to open 
section of Superdome for special needs evacuees (approximately 
400 capacity).
Opened with DSS and DHH staff and supplies  7- Special Needs 
Shelters
Cared for 1200 special needs evacuees pre-storm
Nursing Home Association assisted 19 nursing homes evacuate pre-
storm
LA Hospital Association assisted hospitals evacuate patients that 
were able to travel and admitted patients that were too ill to 
travel 
EMS assisted with the transport of hospital and special needs 
evacuees

Summary of accomplishments by DHH and Partners:  
Hurricane Katrina:
POST-STORM:  
Federal DMAT sent to the Superdome with a DHH Advance Team to assist
with medical needs
Special Needs sheltering expanded at Nicholls State University and 
LSU to establish TMOSAs - Temporary Medical Operations and Staging 
Areas.
LSU - TMOSA, Pete Maravich Assembly Center opened as a surge facility
for emergency rooms with the capacity for 800 beds. Over 40,000 
evacuees were triaged at this facility.
Nicholls State TMOSA, Lafourche - triaged over 20,000 evacuees.
Other Special Needs Shelters around the state expanded capacity to 
care for over 2000 special needs evacuees at one time.
Worked with NDMS to create a Med-evac Program at the Kenner Airport - 
to send 1800 hospital patients out of state.
Sent EMS Teams to Search and Rescue Base of Operations (SARBOO) at the
Causeway to help triage thousands of evacuees.
LA Nursing Home Association helped get resources to evacuate another
34 homes
LA Hospital Association helped evacuate 25 hospitals - 12,000 patients
and caregivers
Evacuated 120 premature and newborn babies to Womanï¿½s Hospital in 
Baton Rouge
Immunizations and pharmaceuticals provided to evacuees in shelters with 
the help of OPH, NDMS, and USPHS.
Assisted with medical professionals and supplies to support West
Jefferson, East Jefferson and Oschner hospitals to remain open 
Coordinated credentialing and placement of medical volunteers
Worked with DMORT to address the deceased

Hurricane Rita
PRE-STORM:
The Special Needs Shelters in Lake Charles and Lafayette moved to 
Shreveport and Monroe respectively.
The Special Needs Shelters in Alexandria and Baton Rouge increased 
their capacity to receive evacuees
School gymnasiums opened to Nursing Homes to evacuate because the 
other nursing home facilities were already filled with Katrina 
evacuees (24 nursing homes evacuated for Rita pre-storm).
19 hospitals evacuated patients within the state with a few patients 
going out of state
Medical needs of general shelters addressed with EMS, DMAT and USPHS 
teams because all shelters were already at capacity.

Hurricane Rita
POST-STORM:
Re-opened Special Needs Shelters and operated a TMOSA in Lafayette to
serve returning Rita and Katrina evacuees
Opened a TMOSA at St. Patrickï¿½s Hospital, Lake Charles
Opened a SARBOO at the Convention Center, Lake Charles
Assisted with hospital surge by accepting hospital discharge patients
to special needs shelters.  
Sent medical professionals and DMAT teams to identified hospitals so 
that they could address surge
Worked with DMORT to address re-interment


The Future:  
Health Careï¿½s Needs to Prepare and Respond to Catastrophic Disasters 

Continue HRSA Grants, with increased level of funding
Reform Stafford Act to include health care costs for catastrophic 
events and long term response
Funding for purchase and pre-staging of generators for special 
needs shelters
Mitigation funds for relocation of hospital generators

Mr. Whitfield.  Thank you, Dr. Guidry.  Thank you so much.
Dr. Agwunobi, Iï¿½m going to ask you a question that Iï¿½m sure everyone on 
the panel wants to ask you.  In your testimony, you say that CMS is 
making sure that the healthcare community is reimbursed for providing 
care.  And yesterday, all of us went on a tour of the University 
system, the Charity system, the Tulane University system, and 
Convention Center where they have the temporary system for the Charity
Hospital system there.  They told us yesterday they were not being 
reimbursed for the care being provided at the temporary emergency 
center because the waiver had not been granted yet.  From the testimony 
that you have given this morning, I get the impression that all waivers
have been granted.  So if that is the case, why are they not being 
reimbursed for the care being provided?  
Dr. Agwunobi.  Sir, if I may, I should clarify.  There are a number of 
waivers that have been signed that are in effect.  They extend all the 
way back to the storm itself, and the immediate days following.  No two 
waivers are the same.  Each waiver accomplishes a different task.  The 
LSU waiver that I think is what we are referring to right now, is under 
consideration.  There are many others that have already been signed.  As 
you are well aware, there has been so much work done by CMS and by other 
agencies.  
Mr. Whitfield.  How long has it been under consideration?  
Dr. Agwunobi.  Iï¿½m actually not aware of when the request was first 
received, but I will get you the exact date.  
Mr. Whitfield.  It seems to me that this hurricane was in August, the 
safety net has been removed from New Orleans, and if there were ever a 
case where a waiver would be appropriate, it seems to me that where you 
have a temporary emergency facility meeting the needs of the people in 
this community that needs so much right now, that that would be an 
incident of where a waiver should be granted.
So, what is your understanding of--is there some legal requirement that 
is not being met, is there some regulatory requirement that is not 
being met?  What is the problem here?  
Dr. Agwunobi.  Sir, Iï¿½m not sure there is a problem.  I have no doubt 
that this particular waiver is being processed in an expedited 
fashion.  Iï¿½m not exactly sure--but I have no doubt that it is being
given a lot of thought and due diligence in as expedited a fashion as 
possible.  CMS is fully aware of the need to move quickly on these 
issues.  We are essential to the people of this community.  I have no 
doubt they are working as fast as they can.  
Mr. Whitfield.  The problem is they are going to be closing that 
facility relatively soon and hopefully going to Elmwood for a temporary 
site, but I would ask you to give a personal message to the Secretary 
that we find it hard to believe that this waiver has not been granted.  
Dr. Agwunobi.  I will deliver that message in person, sir.  
Mr. Whitfield.  Thank you.
Now, Dr. Guidry, we have heard testimony today that one of the reasons 
that Charity has been slow in getting back up to speed--we know that 
there are some issues with FEMA as well.  I would like to ask you, on 
FEMA, how does your part of the country work with FEMA?  Are you all in 
a lot of coordination with each other, a lot of dialogue back and forth 
as FEMA tries to make decisions about when to grant money?  If you were 
speaking to the Rotary Club here in Louisiana, how would you explain 
this interaction?  
Dr. Guidry.  Early in the process they come in and say, "How can we 
help you?"  So you start putting in all these requests.  And everything
medical or health-related comes through the State (inaudible) approval, 
not because I want it that way, but because they want a safety net to
justify the expense.  So, in going through these, and in putting it 
forward, there is a close relationship between the folks that work with
FEMA and saying "I need these things."
There were so many things coming in that keeping a way of knowing what 
was being looked at and going to be delivered became an unbelievable 
task, so you kept putting in these requests and putting in these 
requests.  And you never knew if they were going to say yes.
For instance, I had to deal with one of the things (inaudible) was all 
the deceased, and trying to identify them so we could give them to 
family members.  It took three months to even know what they were 
willing to pay for.  I put two scopes of work forward and they said 
they could take care of it, contract it and do it cheaper than I 
could.  Two or three months later--
Mr. Whitfield.  Are you talking about FEMA?  
Dr. Guidry.  DMAT.  So, over and over again, I guess, the millions and 
millions of dollars, the amounts we are looking at, especially on 
healthcare, I kept getting the answer, "We have never done it before, 
we have to send it up."
So I started going every morning, at 7:30 a.m. in the morning, to the 
Joint Field Office so when they had FEMA and all the folks there and 
Baton Rouge were there, I entered their discussion and gave them my 
needs so they could take it directly to the top, also talking to people 
in Washington at the same time.  And still, the process, you never knew 
to what extent itï¿½s going to be paid.  
Mr. Whitfield.  Let me ask you this question.  FEMA has told us that 
they have either obligated or spent $406 million in healthcare in 
Louisiana, which we know it is going to take a lot more than that.  How 
much has the State of Louisiana spent at this point?  
Dr. Guidry.  At this point, I donï¿½t have the totals, but the State 
(inaudible) on the request for special needs shelters, there is a 
request on the hospital associations, hospitals, shelters here.  It is 
in the hundreds of millions of dollars.  
Mr. Whitfield.  Now, someone testified earlier today that under the 
Louisiana constitution, the only two areas in which there can be a 
reduction in funding is in education and healthcare, and as a result of 
that, I guess, particularly with Katrina and the impact of that on the 
State, Iï¿½m sure the State is struggling with the financial issue here, 
as is the country, as a matter of fact.  But HCA, in their testimony, 
they talked about how they had provided insurance coverage for this, or 
partial coverage, and the State is self-insured.  Is the State 
prohibited from having private insurance coverage on something like 
this, or is it just a policy that they be self-insured?  
Dr. Guidry.  That is something that Iï¿½m not familiar with the details 
on.  I am afraid to answer it in the sense that I may be giving 
misinformation but I will tell you this:  on all the insurance that we 
normally do, itï¿½s through risk management, which is self-insurance, the 
State is self-insured.  So, on our buildings, or repair and replacement 
for our buildings, we work with older systems (inaudible).  Iï¿½m not 
aware of private insurance as part of (inaudible).  
Mr. Whitfield.  So the State is self-insured for the full amount, 
whatever it is?  I mean, most companies that Iï¿½m aware of, when they are 
self-insured, they will pay, like, the first five or ten million, then 
they have catastrophic coverage above that.  Is that the way the State 
of Louisiana operates?  
Dr. Guidry.  I think we are talking about, our catastrophic insurance 
is through the Government.  
Mr. Whitfield.  Okay.  I donï¿½t think I will ask any more questions 
about that.
Mr. Stupak is recognized for ten minutes.  
Mr. Stupak.  Thank you, Mr. Chairman.  Dr. Agwunobi, I have put into the 
record a number of letters written to the Secretary, one on September 6, 
2005, another one on December 15, 2005, and we really need the Secretary 
to answer those letter.  I hope (inaudible) on this issue, but to not 
even get a response or a phone call back.  So I hope we can get some 
answers.
One of the questions Iï¿½m going to ask today is what does HHS believe to 
be the vision of health care after this hurricane, or two hurricanes, 
here in New Orleans?  What does HHS envision the healthcare and delivery
system to be?  In talking with the Charity folks, they testified this 
morning, they have a vision, apparently now HHS has a vision, and it 
doesnï¿½t sound like either vision is working together.  
Dr. Agwunobi.  Sir, the first part of your question, I can assure you 
that the Department is working hard to provide you with answers on those
issues.  The Secretary has personally become involved in his recognition
that there is an opportunity in this tragedy, and an opportunity for 
this city to build something even better than what it had before.  He 
has a firm belief that the Department should serve as a--not only should 
it (inaudible) future resources but it should also be one of the 
catalysts that this great city and State, local, individual players--
Mr. Stupak.  That hasnï¿½t happened.  
Dr. Guidry.  In actual fact, a number of things have occurred, including
a meeting that occurred that the Secretary attended himself in January, 
during which a set of principles were discussed on how this community 
would be formed and how we would map forward and what its goals might 
be.  
Mr. Stupak.  So, we donï¿½t even have a committee yet?  
Dr. Agwunobi.  Actually, I think it started on the premise that it begin
with the Louisiana Recovery Authority, Dr. Fred Cerise, with the State 
Department of Health, is an active player in that.
I also know that there was a follow-up call yesterday on that first 
meeting.  
Mr. Stupak.  Let me move on, because it sounds like (inaudible) HHS, 
sounds like you are going to be a while before you get your vision, so, 
let me ask you this:  Do you know a Dr. Leslie Norwalk?  
Dr. Agwunobi.  I do.  
Mr. Stupak.  Assistant General Counsel?  
Dr. Agwunobi.  Deputy Director of the Centers for Medicare and Medicaid 
Services.  
Mr. Stupak.  She has promised us that there will be answers and no 
problems with waivers.  But we are still hearing that you are waiting for
waivers.  Just reimbursement for the care of people who were in the tents,
or emergency services provided at the Convention Center, if they were 
going to be paying for any of those services, when can they expect to 
be paid for those services?  
Dr. Agwunobi.  I know they are processing and working through the
issuance of that with her, very rapidly, and it is under consideration,
sir.
Mr. Stupak.  (Inaudible) How about the waiver that currently exists, 
which, to my understanding, is due to expire here for those who are the 
residents, the training of doctors who have been placed in hospitals.  
That waiver is due to expire January 31.  Tulane, LSU would like to
extend that waiver if it can be extended.  
Dr. Agwunobi.  I donï¿½t know if we received a request for that, but I
do know that if we have it, it will be placed under consideration and 
acted on appropriately.
Mr. Stupak.  Okay.
Let me ask you about your testimony on pages 10, 11, and 12; you talk 
about CMS relaxing Medicaid billing requirements and accelerated 
payments.  At the top of page 12, you indicated that CMS temporarily
relaxed Medicare billing departments and offered accelerated payment 
options for providers furnishing such care.  Do you know of any 
provider--in New Orleans--who has been offered accelerated payment 
options?  
Dr. Agwunobi.  I donï¿½t.  
Mr. Stupak.  Well, how did you get the facts for the statement and your
testimony, then, if you donï¿½t know of anyone who received them?  
Dr. Agwunobi.  The impression, if I may, in New Orleans--I donï¿½t know, 
but I do know for a fact that this waiver was (inaudible) allowing 
providers to take advantage of it.  What Iï¿½m not clear on is whether or 
not any have.  
Mr. Stupak.  The other members on the panel have told us they have not 
received any payments.  You are telling us you know for a fact that it 
was offered, so, if they didnï¿½t receive any, and you donï¿½t--you saying 
that people have been offered the opportunity just doesnï¿½t jive.  It 
just doesnï¿½t--those two statements are inconsistent.
Let me ask you this:  CMS instructed its contractors to facilitate 
processing of claims for services furnished by physicians during the
(inaudible) settings, for example, shelters outside the normal setting. 
This would include the tents at the Convention Center, would it not?  
It is outside the normal settings.  
Dr. Agwunobi.  Iï¿½m not sure if the tents at the Convention Center is
what this particular waiver was aimed at.  Once again, I recognize
that there is a particular waiver that has been requested by the 
University system for this particular site, and that is under 
consideration.
Mr. Stupak.  But you donï¿½t know when the consideration will be done?  
Dr. Agwunobi.  No, sir.  
Mr. Stupak.  How about at the bottom of page 12, you said, "Accelerated
and advance payments were available to those providers who are still 
rendering some services or taking steps to be able to furnish services 
again, despite having their practice or business affected or destroyed 
by the hurricane."  So, Charity, which is obviously providing a service,
you heard today is trying to negotiate a lease, they should be receiving
payments, accelerated or advance payments, right?  
Dr. Agwunobi.  Iï¿½m not sure if this particular provision would apply to
them.  I can check for you, sir.  
Mr. Stupak.  If you donï¿½t know if these provisions for paying these 
providers apply here in New Orleans, why then would that be included in 
your testimony?  
Dr. Agwunobi.  My point is that I donï¿½t know the specifics of any 
individual entity or provider as it relates to these waivers.  It would 
be inappropriate for me to testify as to specifics.  
Mr. Stupak.  I wouldnï¿½t think that HHS would want a witness who couldnï¿½t 
testify about the situation in New Orleans (inaudible).
Let me ask you this one.  There is a program called the Community 
Disaster Loan Program.  It is a (inaudible).  I know Charity has applied 
for one of those.  Do you know what has happened to their application 
for a Community Disaster Loan Program loan, so that they can remain 
operating?  Do you have any idea on that?  
Dr. Agwunobi.  For Charity, I donï¿½t.  
Mr. Stupak.  Do you know of anything in the Stark Amendment that would 
allow providers to provide assistance to physicians practicing at 
hospitals outside the service?  
Dr. Agwunobi.  No.
Mr. Stupak.  You donï¿½t know that?  Have any of the hospitals in this
area applied for that?  
Dr. Agwunobi.  You would have to ask the hospitals that.  
Mr. Stupak.  I understand the Stark waiver will expire on January 31.  
Will you take it back to the Secretary and tell him to get it done 
before January 31, so that these physicians--because these residents are
not going to be back here by February 1st practicing medicine.  
Dr. Agwunobi.  I will relay your message.  
Mr. Stupak.  Does the HHS have a commitment to reopen Charity Hospital 
as part of your vision?  
Dr. Agwunobi.  Iï¿½m sorry, sir.  
Mr. Stupak.  Does the Administration have a formal commitment to help 
reopen Charity Hospital as part of their vision for healthcare here in 
New Orleans?  
Dr. Agwunobi.  When you refer to the Administration, are you referring 
to the Department of Health and Human Services?  
Mr. Stupak.  Sure.  
Dr. Agwunobi.  Sir, we believe firmly that the decisions that are made
on a provider by provider, hospital by hospital basis should be made at
the local level.  Our job should be to support, No. 1 the--
Mr. Stupak.  Then there is no need for the Administration to have a 
vision, it should be determined at the local level, right?  (Inaudible).
Dr. Agwunobi.  Thatï¿½s right, and I think there has to be a vision at our 
level.  It has to be one that sets forth (inaudible), that demands and
expects cooperation.  
Mr. Stupak.  Some of these questions Iï¿½m asking--like about the vision--
those were in letters of December 15 and September 6.  Iï¿½m asking you 
now because we still havenï¿½t had any answers.  Please have whomever is
in charge of answering those letters to answer them, so we can get some
answers to our questions.  
Dr. Agwunobi.  I will relay your message, sir.  
Mr. Stupak.  Let me ask you this:  we heard testimony today about 
patients removed from one hospital to the Louis Armstrong Airport, and 
the healthcare professionals from those hospitals trying to help and
being told they could not help.  Then patients were sent wherever.  
Would HHS have made the decision to do that?  
Dr. Agwunobi.  Iï¿½m not sure that would have been (inaudible) that would
be managed in the field and they were consistent with the events that 
were (inaudible) occurring during the storm.  
Mr. Stupak.  But HHS had people in the field during the time of the
storm?  
Dr. Agwunobi.  Thousands of people.  That particular operation was, of
course, managed by a different entity, from what I heard today.  
Mr. Whitfield.  At this time, we recognize Dr. Burgess for ten minutes.  
Mr. Burgess.  Thank you, Mr. Chairman.  Although in your absence, I 
gave myself some additional time.  On the issue of credentialing, I 
have to ask either Dr. Agwunobi or Dr. Guidry, I believe you actually 
referenced this, I just think it will be extremely helpful to know.  I 
have practiced for 25 years and I did not know of such a credentialing 
policy.  Basically, I went on the Internet to find out.  That is a 
useful tidbit of information for any of us who actually practice, that 
if a disaster occurs, that we would be able to be there and take care of
our patients, either at a field hospital or--so I think that is an 
extremely important concept to develop and make known to hospitals and 
medical staff, that HCA, as a corporate decision, had decided to 
sponsor. That seems to be an extremely good idea and an example of 
forward thinking.  And maybe others could do similarly.  What was the 
acronym you told us?
Dr. Guidry?  
Dr. Agwunobi.  It might have been when I was referring to the emergency
system for a fast registration of volunteer health professionals.  It
existed in 13 States prior to the storms.  Quickly as the storms 
approached, seven States were brought on.  It is our intent, I think we 
are up to 30-something States as we speak.  All States have the ability 
to have this expedited credentialing for volunteers.  
Mr. Burgess.  And I stress it is a good idea because the guys on the 
ground should have been making the decisions and relying on hospital 
staff.  The poor guy with the DMAT team doesnï¿½t know that.  It is his 
responsibility to protect the Federal government from liability, 
because they are going to be practicing under the Federal governmentï¿½s 
liability with the practicing facility.  
Dr. Guidry.  If I could shed some clarity on that.  One of the things I 
had to deal with during this chaos and trying to take care of patients 
were all of the volunteers showing up and wanting to help.  Managing 
that becomes difficult because a lot of folks come expecting to do 
what they are trained to do.  They are not willing to do just anything
you need.  Two, you have to find out if they are credentialed.  The 
Governor had an executive order that allowed other people to come from
other States and practice medicine.  The Office of Public Health, we
were quickly looking to see if they were licensed and could do this. 
So, the HRSA bill is something proposed--that HRSA has been proposing
that you do, before you have this all happen.  It is a monumental task 
and keeping track of peopleï¿½s credentials and training, as you know, 
keeping track of your own individual one is a monumental task.  
Mr. Burgess.  Let me cut you short because we need to talk about 
waivers a little bit more.  I heard the Secretary on Labor Day weekend 
tell the doctors at the tents in Dallas that there is a waiver, you 
will be paid, but I came down here in October, and I got the impression
from private physicians who were conforming to all of the things they 
were asked to conform with that they were not being paid under these 
waivers, under their own clinics or institutions, or when they saw
patients in the emergency rooms of their hospitals that were up and 
running.  This is an extremely important situation, and I would add to 
what Mr. Stupak said.  I urge you to get the Secretary or the 
Administrator to rule on this.  It is of utmost importance to 
preserving what is left of the safety net here on the ground, and 
allowing them to build, going forward.
The concept of the money following the patient in a situation like this 
is that something that we can help you with?  It seems like a 
fundamentally straightforward and common sense way to approach a 
disaster situation, that rather than have the patient fit into a neat
category of whether itï¿½s FEMA, or HHS, CMS waiver or grant or what have
you, just have the money following the patient, and let the doctor or 
hospital or nurse practitioner be reimbursed for the care they deliver. 
I mean, thatï¿½s what itï¿½s all about, right?  
Dr. Agwunobi.  I recognize how frustrating it must seem.  I can tell you
this, that even within the Department we are looking at all of our 
processes and learning from this storm as we did from prior storms.  
And I have no doubt that as that review, as that process of learning is 
underway, that where we find the opportunity to have you help us 
improve the system, that our Secretary will reach out to your services 
or your organizations as is appropriate.  
Mr. Burgess.  It makes sense if you do the same thing with schools as 
well, and let the money follow the student.  While things--while the 
structure is not in place to do what weï¿½ve always done, to at least 
allow the child to continue to receive the education and the patient 
continue the medical care, and the person who is doing the work for 
that would get paid so that they can continue to do that good work.  It 
just makes sense to me and I donï¿½t understand why we donï¿½t do it that 
way.
Now, there were the community development loans that were passed and 
signed into law in October, I believe, or right at the end of September, 
and how have we done with those?  Are those loans coming to the 
healthcare institutions that are the ones that were left up and 
running?  Ochsner, for example, would they even be able to participate 
in that, since they are an entirely private entity?  
Dr. Agwunobi.  I have to admit I donï¿½t know the details of how many.  
I do understand that that process is under way.  
Mr. Burgess.  Again, maybe you could look into it.  I know the East and 
West Jefferson Parish Hospitals are governmental entities, and would be 
suitable for those types of loans and I would just be interested to 
know where we sit with that today, because, again, that legislation was 
passed rather hurriedly, and I think that was the end of the first week 
in October, and we are now well into a new year and it would be nice to 
know if that money is getting where it was designed to go.  
Dr. Agwunobi.  I will make sure that the committee is updated on that.  
Mr. Burgess.  I mean if it has just been sitting there for a quarter in 
someoneï¿½s account, I donï¿½t even know if itï¿½s drawing interest.
On the evacuation aspect, and this is something I didnï¿½t bring up to the
other panel, because I donï¿½t even know if itï¿½s appropriate.  I spent some 
time in Iraq, where they have the contingent medical facility, and they 
took the wounded from all over the battlefield to a central location and 
stabilized them, operated if necessary, took them to Germany, and then
they were flown back to Walter Reed Medical Center.  Sitting on the 
sidelines in another State and watching a system made up as we went 
along-- (inaudible).
I will yield back my last 15 seconds.  
Mr. Whitfield.  Thank you very much.  I appreciate your generosity.  I 
would like to make one comment.  There seems to be some discrepancy on 
the timeline for the request for waivers from HHS to reimburse the 
temporary emergency room care at Charityï¿½s Convention Center.  So, I 
would like to ask Dr. Fontenot and Dr. Agwunobi if you-all would submit 
to the committee the time lines as you understand them, the time lines 
for the request for this waiver.  We have one letter here thatï¿½s dated 
like January 10, and we have one letter from the State of Louisiana 
dated December 15.  I know that we all want to expedite this, but I
think it would help us get a little bit better understanding if you-
all would be willing to do that with supporting documents.  Thank you.  
Mr. Stupak.  May I add that besides a formal application for these 
waivers, if Dr. Agwunobi and the others could put in there the times 
when they had discussions about the waivers.  As the record will 
reflect, the letters I put in earlier, especially the one from 
December 15 that I wrote along with Mr. Dingell and others on this 
side of the aisle that actually wrote letters, question No. 15 said,
to the Secretary of HHS, "Charity Hospital needs a waiver from CMS 
to bill for services that it is providing in its tent facilities.  
What is the status of the waiver and any other CMS waiver of 
requirements that would be necessary for payment?"
So, even back on December 15, Charity was frustrated because it could
not get any kind of answers.  So, we actually put in a letter thinking
maybe a congressional letter could get some answers, and we still donï¿½t 
have any answers.
And with the admission of this document, which we admitted earlier, I 
have no objection to your letter of January 10.  
Mr. Whitfield.  Yes, and also, LSU will be submitting their time line 
as well.
At this time, we recognize Ms. Schakowsky for ten minutes.  
Ms. Schakowsky.  I think you can tell from the nature of the questions, 
that this panel, as well as the people who have testified before it, 
feel frustrated in being able to accomplish on the ground what they need 
to do--in some part, maybe not in large part--and then again, a 
catastrophe makes us all improvise in many ways and do what needs to be
done, but it seems to me that the role of the Federal government to not 
just to sit back and say, "You need to apply for this, you need to apply 
for that."  Or, "Well, we couldnï¿½t do anything because you didnï¿½t know 
about that waiver," or "It didnï¿½t come in time."
It seems to me in the midst of a catastrophe, that the Federal 
government can be proactive and come to the State and the hospitals and 
the localities and say, "We see the problem that you have.  This is in 
our arsenal of things that we can deal with, how can we help you deal 
with this?"  And, "We are going to help you figure out exactly how.  In
fact, maybe someone on staff could even help you draft something."
I mean, is that outrageous?  It feels to me like there is almost a 
certain amount of "gotcha" here.  You know, you said Iï¿½m not sure there 
is a problem, referring to the waiver for payments for the Convention 
Center tent facility.  Well, if the justification for saying that is 
because the letter didnï¿½t arrive until January 12, Iï¿½m saying, shame on 
you.  We had a December 15 letter that some of our Democrats on the 
committee sent to you.
In other words, look at the problem, how can the Federal government be a
partner and then how can we help you actually do that.
We know, some of the Democrats on the committee have had the experience 
of not even getting a phone call that says weï¿½ve received your letter, a 
letter that took a lot of work.  This was not just written on the back of
a napkin.  This is a many-page document outlining our understanding of
the problem--and how many questions is it--we have specific questions.
And then, you are coming hear today saying here is this thing we have 
with the Federal government, but we donï¿½t know if it applies to 
Louisiana.  Quite frankly, I think it is really insulting.  I think you 
need to come armed with exactly those things that Louisiana needs.  You 
knew what the questions would be.  If there is a program or some sort of 
reimbursement plan, then you need to know how it applies to Louisiana.
I wanted to ask Dr. Guidry a question.  We heard just today that there 
is this 400-plus million dollars of FEMAï¿½s--who, by the way, Iï¿½m sorry 
is not here on this panel to answer some of these questions--but have 
you seen the $400 million?  Do you know anything about it or how it is 
supposed to be spent?  
Dr. Guidry.  Thereï¿½s been different amounts that have been told to me:  
$300 million, $400 million thatï¿½s sitting there for you.  And so, I have
not seen that funding.  All I keep doing is filling out the requests and 
filling out the project worksheets about what we want and what we need to 
be reimbursed.  I have got way over that amount in requests.
So, I donï¿½t know about a specific amount of money.  I know they put aside 
some money but we have more requested than they put aside.  Most of it
goes back to debating about whether it is something FEMA covers, because 
it is health related.  I have even had the State helping me, which is a 
little frustrating.  Public Health Services and those folks have been 
wonderful in helping me to fill out my requests, because I was so 
overwhelmed, and they did help me do that.
I even heard from FEMA that what they learned in Floridaï¿½s events--and
this is what was killing me--is that when Public Health asks for a 
request, they need to look real hard at that because the Stafford Act 
doesnï¿½t cover a lot of those requests.  I think health requests are
really delayed compared to all other requests.
We removed half the debris that has occurred in this disaster.  Debris.
And the people that are getting hurt removing it, we canï¿½t take care of
them.  So there is a huge gap here as to what is critical and what is 
important.  Half of that debris is a tenth of what they removed in 9/11. 
That shows you how much debris we have.  You saw some of it.  Well, 
people get hurt removing it, and when healthcare asks for something, it
gets pushed back.  So if that exists, it has not been readily 
forthcoming.
There have been a number of requests for paying health professionals so 
they can keep their practices going and so they donï¿½t leave, and we 
canï¿½t figure out how to do that.  
Ms. Schakowsky.  I met with one of those doctors this morning who said
he is starting over; theyï¿½re going into their savings.  Heroic efforts 
for health professionals and institutions to keep it going.  It seems to
me the very least that the Federal government can do is help everyone 
figure out how to work their way through the bureaucracy.  I mean, it 
is not right that when we have the HCA, who has private insurance, those 
checks, Iï¿½m assuming, have come through, they have been able to transfer 
their people within their own system.  Thatï¿½s great.
But when applied to poor people, and public health dollars, it has just
been a morass, a maze of trying to figure it out.  I just think that
issues of the credentialing, on waivers, on reimbursements.  I mean, I
certainly donï¿½t know all of these acronyms and letters, and Iï¿½m in
Congress; and how people sitting in the midst of a catastrophes would 
know--so I think Iï¿½m talking about attitude here and I just wondered if 
you wanted to comment on that.  
Dr. Agwunobi.  I urge you to forgive me if I seemed as if I was being 
flippant or insulting.  I didnï¿½t mean to imply that.  The premise was
Iï¿½m not sure if there is a problem with the process.  Iï¿½m not sure if
we have identified a problem--
Ms. Schakowsky.  There is definitely--can I tell you?  There is a 
problem with the process.  Do you need to hear any more?  There is 
clearly a problem with the process.  We all need to work together to 
figure out how to smooth that out, but there is no way you can be in 
this city and say there is not a problem with the process.  That is 
obvious.  
Dr. Agwunobi.  I wasnï¿½t speaking to the general process, I was speaking 
to that specific waiver, since it has been applied for, whether or not 
during its review of that waiver request, whether or not there is a 
problem in that waiver.  I donï¿½t know.  That was my response.
In response to your letter, I concur that the letter appears as if a lot
of work went into it and I would only respond by saying that the 
Department of Health and Human Services is putting just as much effort
in drafting a response.  
Ms. Schakowsky.  Do you have any authority to give answers to the 
questions that were in that letter?  
Dr. Agwunobi.  I believe that that letterï¿½s response is being worked 
on, even as I sit here.  
Ms. Schakowsky.  Let me just make a suggestion:  It would have been a 
good idea over a month later that at some point somebody would have made
a phone call and said "Weï¿½ve received your letter and weï¿½re working on 
it and hereï¿½s when you can expect it."
Thatï¿½s the other thing:  Time, these things are all happening in real 
time and people are in desperate situations right now.  And we are going 
to be heading toward another hurricane season, there is Mardi Gras 
coming up, there is the flu season coming up.  So, our Government has to
take extraordinary means to help facilitate and smooth that out.  It is 
not business as usual.  Thank you.  
Mr. Whitfield.  Thank you.
Mrs. Blackburn, you are recognized for ten minutes.  
Mrs. Blackburn.  Thank you, Mr. Chairman.  I want to thank both of you 
for being here.  And Dr. Agwunobi, as you can see, we are all 
frustrated.  The bureaucracy, as I said in my opening statement, has 
become so overpowering and convoluted and so elusive.  I can understand
the elusive nature of many of your responses, because you are dealing 
with a bureaucracy that doesnï¿½t want to give concretes.  Iï¿½m sure if we
were to give you the pen, as I offered to the panel previously, and 
said, put a line through things that donï¿½t work, tell us what doesnï¿½t 
work, and that folks there at HHS would have some thoughts as to what 
they would do, because there is a lot that is getting in the way.  We 
have got a lot of red tape thatï¿½s getting in the way in getting around 
to providing healthcare and providing funding.  And I do hope that the 
message that you carry back today is that it is time to look at making
Government more workable and more responsive and that people are very 
tired of empty answers and very tired of hearing things like, "a 
response is being worked on as we speak."
Well, why in the world wasnï¿½t that response worked on a month ago?  
You knew the letter was coming.  And there should have been a response 
in the works then.
As long as I have--and I would encourage you all on the administrative
side of the table to remember this is a government of, by, and for the 
people.  And that is very important, that that be a part of your mission
statement as you move forward every day.
One question for you: every time we have a disaster, a hurricane, 9/11,
Oklahoma, do we have this many problems with the disaster?  Do we have 
this many problems in other States, or is it more difficult than it has
been in other areas?  Is Katrina more difficult than any other disaster
we have ever had?  Is it unique?  
Dr. Agwunobi.  Probably given that so many disasters have occurred over 
hundreds of years, Iï¿½m probably not qualified to comment on a relative
scale of how one ranks with the others.  I can tell you that Katrina 
was unique in its scale and scope, and it wasnï¿½t just a fast ball, it
had curves, twists, and turns.  The levee breaking after the storm had 
passed by, those kinds of things.  
Mrs. Blackburn.  There was forewarning in a report written in 1999 on 
the post-impact.  
Dr. Agwunobi.  I concur.  There are really two parts in every disaster
that go to its eventual impact.  One is the nature of the crisis itself,
the other is the ability of the community to respond to that and to be 
ready for it.  
Mrs. Blackburn.  To quicken the answer a bit, is this that unique?  Do 
you have this kind of problem in other States?  Are the layers of 
problems more unique to Louisiana than you have seen in other States? 
Like the Florida hurricanes and other areas?  This is what Iï¿½m trying
to gauge.  
Dr. Agwunobi.  I worked in Florida through six hurricanes.  
Mrs. Blackburn.  Did you have this many problems?  
Dr. Agwunobi.  Each storm gave us a different set of problems and this 
was a unique storm.  
Mrs. Blackburn.  Dr. Guidry, looking at your plan that you have got, 
the health readiness, and I appreciate your presentation on that and 
the readiness that is, or the preparation going through there as you 
look at readiness.  The State Evacuation Plan, now, in developing that,
does that come under your department, the State Evacuation Plan?  
Dr. Guidry.  The State Evacuation Plan is under the Department of
Homeland Security and Emergency Preparedness.  
Mrs. Blackburn.  But you-all have your interface and component with 
that?  
Dr. Guidry.  Yes.  
Mrs. Blackburn.  The inspection of the hospitals with their permits,
does that come under you?  
Dr. Guidry.  It comes within our Bureau of Health Standards in our 
department.  
Mrs. Blackburn.  So that is in a subdivision of your department?  
Dr. Guidry.  Licensing.  
Mrs. Blackburn.  Getting back to the operational end, which is where I 
have gone through this hearing, was it your department that was holding 
the investigations and the reviews on these hospitals, being certain 
that they had the supplies, that their generators were moved?  I mean, 
were you-all giving the permits and doing these inspections?  
Dr. Guidry.  There are two pieces to this.  It is not a simple answer.  
Mrs. Blackburn.  Give me a yes or no on this.  Did you-all do those
inspections?  Iï¿½m seeing heads nodding yes.  
Dr. Guidry.  Some, yes.  
Mrs. Blackburn.  Why were you giving a permit to hospitals that still
had generators in the basement?  
Dr. Guidry.  The Bureau of Health Standards, I put the question to them,
because it is not something Iï¿½m intimately familiar with.  
Mrs. Blackburn.  Would you get an answer from them for me?  
Dr. Guidry.  Their answer is they look to see if they have a plan, not
to see if it is workable.  
Mrs. Blackburn.  There again we have plans with words on paper, but we 
donï¿½t have an implementation strategy that would carry out the plan in 
case we ever needed the plan to go in place.  
Dr. Guidry.  To that issue, yes.  
Mrs. Blackburn.  All right.  That answers a question I have been 
scratching my head over since September 1.  
Dr. Guidry.  I understand.  So have I. 
Mrs. Blackburn.  So, we never thought we were going to have to put the 
plan in place, and the plan was written on paper, but nobody ever 
thought that in a million years we would really have flooding and that 
the generators would really be out of the basement, and we would really
need to have batteries for the radios?  
Dr. Guidry.  There is no simple answer.  I knew of the generator issue.
When I went around and networked with hospitals as State Health Officer,
we had discussions about how do you get your generators moved, they are
not in the right place.  There is no one sitting at this table this 
morning that would tell you that they didnï¿½t know that was not a good 
plan.
Getting it changed or funded when it has been there for all these years, 
thatï¿½s the issue.  
Mrs. Blackburn.  Dr. Guidry, thank you for your forthrightness.  I thank 
you so much for being here and talking with us and working with us on 
this, and as I said earlier to the gentlemen and the lady that were at 
the table, we really want to be your partner.  There are some lessons 
here that should be lessons learned.  Government is too big.  It is not
responding quickly enough, and I do hope that Dr. Agwunobi takes that 
message back.  I do hope that, from you-all, that everyone understands,
there has got to be a course of action.  There has to be a communication 
plan.  When we look at this analog spectrum and make that available, I 
hope that we address the need for our military and first responders to 
have an ability to interface on that so that communications are made 
easier.  I hope there is an allowance through VoIP on some of the 
broadband spectrum that will allow some additional communications for
you-all.  And I hope that we remember when all else fails, that there
has to be plan Z. When the cell phones are not working and the hard 
lines are down, and the electricity is gone, you have got to have a 
plan to move people and take care of the needs, to be able to meet the 
needs of those that are most at need in our communities.
Thank you very much.  I want to thank the Chairman and staff and other 
members who worked on this.  I yield back my time.  
Mr. Whitfield.  Thank you.  Dr. Guidry, we genuinely appreciate your 
testimony today, and Congressman Jefferson was with us yesterday as we 
toured these facilities, and he wasnï¿½t here this morning with our other
guides, Congressman Jindal and Congressman Melancon.  So, weï¿½d like to
give him the opportunity to make a statement for the record.
We really appreciate you being with us yesterday as we toured the
hospital and we want to thank you for the great leadership you have 
provided to Congress on healthcare issues and being the spokesman for
New Orleans and your constituents.  With that, I will recognize you for
your five minutes.  
Mr. Jefferson.  Thank you, Mr. Chairman.  I am grateful for this
opportunity to address the committee today.  More than that, Iï¿½m 
grateful for the committeeï¿½s visit to our area and for the hearing you
have held here.  It is important, as you noted yesterday, that as many
members of Congress who can come out to see what really is going on 
here and what people are struggling with, but also, how I think with 
great courage and commitment they are dealing with these issues.  We 
saw yesterday as we toured the commitment of our healthcare professionals
to bring back these institutions.  We were a healthcare delivery system
that had wonderful teachers and hospitals, where we had wonderful 
emergency treatment facilities, where we had wonderful facilities here
to care for our children and pediatric facilities.  We have gone from 
a 2,100 bed capacity to just a few hundred beds now.  That is not
nearly enough to build our city back up.  And people donï¿½t want to be 
part of this great New Orleans unless we can get our levees right, get 
our housing right, and get our healthcare right.  Unless they know that 
there is a chance, if they are in trouble, they have someplace to go 
and be attended to, there is no chance we will be able to bring our 
city back.
So, this is critical to us and your visit here and the message you take 
back will do a lot toward us building back our region.  So thank you very
much for what you have done.
We have had Members of Congress dealing with levee and water board and
transportation questions.  This is the first time we have had the 
healthcare issue spotlighted, and it really-- there is not a whole lot 
more important things.  Without this aspect being taken care of, there 
is no chance we can build back our city.  So, your work is important, 
your presence very, very much appreciated.
We saw yesterday at our teaching hospitals, it is not just a matter of 
service to our people, it is also a matter of the future of the 
healthcare profession and who will be in our city and our region.  So,
this thing has more than one dimension to it, and we are very, very
keen on making sure that we bring back not only the capacity we had 
before, not only the facilities we had before and not only the top
people we had before, but to build a future here, and we are building
something very important here and centralizing a great healthcare 
service system which we want to help get back on track.  Your presence 
helps us to focus on that and get our people back online to restore our
healthcare facilities.  So, thank you all very much for your presence.  
Mr. Whitfield.  Before we conclude this hearing, we have all been moved 
by a number of specific issues that were raised, but we intend to 
follow up on those issues and we are going to be as helpful as we can
be in helping you address this problem and in getting the healthcare 
system back in full operation.  And we are going to leave the record 
open for ten days for the questions to be submitted and then another 
30 days to provide answers to those questions.  With that --
Mr. Stupak.  Before we leave, if I may, I hope we will continue this.  
You indicated in your statement at the end here that we will continue
to monitor things, but I hope more than monitor.  I hope we have more 
hearings, and I would like to hear from FEMA, I would like to hear from 
the person in charge of these waivers at HHS.  And I hope to move this 
along.  Youï¿½ve been generous with your time:  ten days for questions 
and 30 days for answers.  Thatï¿½s 40 days, and I hope we can set another
hearing then in Washington for all of us to go over this together.  This
hearing is a small step toward that eventual goal.  
Mr. Whitfield.  Thank you.  Also, I do want to thank General Downer and 
the National Guard for their assistance yesterday.  Certainly, the Chief
Justice, who has just walked in the back, we thank him for letting us 
use this courtroom.
With that, the hearing is adjourned. 
[Whereupon, the subcommittee was adjourned.]
 
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