[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
Available via the World Wide Web:
http://www.access.gpo.gov/congress/house
___________
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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 we�re 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 don�t
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 don�t 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 isn�t--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. We�ve called this hearing to examine hospital
disaster preparedness and look especially closely at the horrific
experiences - and hard lessons - of New Orleans� 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 Orleans� 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 Katrina�s 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 we�ll hear directly from some of the hardest hit hospitals,
which remain shut down five months after the storm - the Tulane and
HCA hospital, Tenet�s Memorial Hospital, Louisiana State University�s
Charity and University Hospitals and Universal Health�s Chalmette
Medical Center. We�ll also hear from West Jefferson Medical Center, a
hospital that was spared the flooding and operated through the
disaster�s aftermath and is now one of the essential facilities
handling New Orleans current medical needs.
We�ll 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. I�m 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.
We�ll 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 didn�t, 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 we�ll 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 haven�t 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, we�ll 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. I�m 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 Louisiana�s 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 hasn�t 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 won�t 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
I�m 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
can�t 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 Charity�s 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? Charity�s 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, I�m 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. That�s 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
can�t 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 didn�t even have a light on. It didn�t 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? I�m 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, I�m 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. Let�s 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 region�s 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 �play
musical chairs� 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. "That�s 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 region�s largest hospitals: Big
Charity and University Hospital. Known together as
"Charity," both were severely damaged by Katrina�s 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 hospital�s patient base (or approximately
275,000 of the region�s 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 region�s 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 Committee�s
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. Smithburg�s 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, "it�s 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 didn�t 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 don�t 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--I�m particularly interested
in the hospital�s 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 don�t 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
don�t 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 we�re 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 I�m 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 colleagues� thanks
for holding this hearing down in New Orleans. I also want to echo my
colleagues� 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 hospital�s 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 doesn�t 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 don�t 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 don�t 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 region�s 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 I�m
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 hasn�t 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, that�s 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, I�m 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
y�all--that is plural for you-all--for being here, because all of
y�all�s healthcare system--and that�s 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
I�m 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. I�m 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
can�t. 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 Children�s 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 don�t 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 haven�t seen, I don�t 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 weren�t
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 doesn�t 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 don�t
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 don�t 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 wasn�t 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 wouldn�t 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 Louisiana�s 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 city�s 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.
I�m 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 he�s 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 Louisiana�s
Senior Level Health Healthcare Executive Regent�s Award for 2004 from
the American College of Healthcare Executives.
You have got his biography in front of you. I won�t go through all of
his particulars, but I do want to say that is a well-deserved honor,
when you consider his staff�s and his medical center�s 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 Louisiana�s 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 organization�s 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. HCA�s Delta Division encompasses
Louisiana and Mississippi. As Delta Division President, I have taken
an active part in formulating HCA�s 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. HCA�s 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. HCA�s 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.
HCA�s 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 HCA�s 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 manual�s 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 government�s 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 HCA�s 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 company�s 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 Center�s 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 hospital�s 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 Women�s and
Children�s 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 hospital�s response to the greatest
natural disaster in our nation�s history.
Apart from my account of the evacuation itself, let me now give you
a sense of the magnitude of HCA�s response to Hurricane Katrina. In
terms of supplies, HCA provided the following to aid Katrina�s
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.
HCA�s 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. HCA�s
hospital business partners and vendors, including the Rapides Foundation,
St. David�s 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 hospital�s 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 organization�s 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.
HCA�s Delta Division encompasses Louisiana and Mississippi. As Delta
Division President, I have taken an active part in formulating HCA�s
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. HCA�s 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. HCA�s 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.
HCA�s 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 manual�s 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 government�s 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 HCA�s 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 company�s 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 Center�s 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 hospital�s 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 Women�s
and Children�s 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 hospital�s response to the greatest natural
disaster in our nation�s history.
Apart from my account of the evacuation itself, let me now give you a
sense of the magnitude of HCA�s response to Hurricane Katrina. In terms
of supplies, HCA provided the following to aid Katrina�s 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 727�s 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.
HCA�s 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. HCA�s hospital
business partners and vendors - including the Rapides Foundation;
St. David�s 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
hospital�s 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. I�m 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 Tulane�s 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
building�s 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 TUHC�s main campus, which currently is
closed. Although we are several months from restoring full operations,
I have great confidence in HCA�s 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 Plan�s
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 Katrina�s 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 TUHC�s 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 HCA�s 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. HCA�s 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 TUHC�s policies and procedures for emergency
preparedness management. I also witnessed the Plan�s 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. TUHC�s 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 TUHC�s 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
TUHC�s 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 structure�s training and implementation results in
multiple individuals� 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
HCA�s Corporate Disaster Team ("CDT") and other HCA hospital and
organizational staff for support in navigating the unimaginable
devastation.
II. TUHC�s Severe Weather Program and Total Facility Evacuation
Plan
Before relating my experiences with Hurricane Katrina, I would like
briefly to describe TUHC�s 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 Coast�s 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 Service�s 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 Program�s
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. TUHC�s 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 Katrina�s 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 TUHC�s 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 TUHC�s
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
facility�s 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
hospital�s "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, I�m 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 Memorial�s operations during this tragedy, I would
like to speak about Memorial�s 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 Katrina�s
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 city�s 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 hospital�s 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 Memorial�s resilience, courage, and dedication in the face
of one of the Nation�s 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 company�s 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, I�m 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 Tenet�s Memorial Medical Center in New Orleans, Louisiana, I
led Memorial�s ground floor preparation and response efforts related to
Hurricane Katrina.
Despite unprecedented devastation caused by Hurricane Katrina, including
the failure of the city�s 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 Nagin�s 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 city�s 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 Memorial�s
operations during this tragedy, I would like to speak about Memorial�s
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 Katrina�s 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 city�s 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 Memorial�s 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 Memorial�s 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 didn�t 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 hospital�s
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 nation�s 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 Tenet�s 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 can�t 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
company�s 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 I�m 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 couldn�t 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, I�m 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 doesn�t 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 couldn�t 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
doesn�t 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
Tenet�s 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 Tenet�s 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 Tenet�s 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 storm�s 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 city�s 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 O�Bryan, 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 office�s 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, Tenet�s 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 Tenet�s 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 NorthShore�s 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
Kenner�s evacuation was complete by about 8 p.m. using both ground and
air resources.
In addition, private aircraft took the last of Memorial�s 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 didn�t
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 use�as human
waste containers.
�
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.
�
Specific Hurricane Katrina Preparations
�
Thursday 8/25/05
Conducted dietary and pharmacy assessment of inventories in advance
of the storm.
�
Saturday 8/27/05
8 am:� Katrina�crosses 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 of� intent�to raise
Code Grey status to full activation
�
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.
�
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.
�
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.
�
Loss of patient life was minimal and limited to critically ill patients.
�
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 facility�for 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 State�s 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 storm�s 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 hospital�s obligation to gear up in potential
disasters and to continue to operate when others may not be able to
do so.
LSU�s 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 Louisiana�s 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 we�ll 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 harm�s way. We did not wait for the
established cavalry, as we did after Katrina�s 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 can�t
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 don�t 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 Louisiana�s 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 state�s 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 storms� 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 hospitals�
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 Louisiana�s only Level I trauma and
specialty care centers - in New Orleans and Shreveport - are
operated by LSU, special medical needs can be accommodated internally.
Louisiana�s 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 Louisiana�s 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 didn�t wait for the established
cavalry as we did after Katrina�s 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 nation�s 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 LSU�s 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 harm�s 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 sheriff�s 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 sheriff�s 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 parish�s sheriff
and fire department for providing extraordinary care during one of this
Nation�s 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 hospital�s
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 it�s 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 (CMC�s 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 sheriff�s 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
sheriff�s 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 it�s 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
sheriff�s and fire department for providing extraordinary support during
one of this nation�s 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.
FEMA�s 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 Jefferson�s 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
hospital�s 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 region�s 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 Jefferson�s citizens
but to the region.
FEMA�s 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.
LSU�s 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 I�m 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 Parish�s instance, the emergency
operations state that�s controlled by the parish president and we
receive direct orders because we are a parish facility.
Mr. Whitfield. But you don�t 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. I�m assuming that the major difference--I mean,
the Tulane hospital is going to be up and operating for limited services
relatively soon, and I don�t get the impression that University and the
Charity Hospital are going to be in a situation to do that anytime soon
now.
I�m 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 investors� dollars in, and yet, at
Charity and University, you are totally depending, I�m 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 State�s 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. That�s self insurance?
Mr. Smithburg. That is my understanding and I�m 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 Charity�s 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, I�m assuming you can�t 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 LSU�s 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 don�t know, but you are basically
sending your patients to other entities that you own.
Mr. Lagarde. That�s 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
harm�s way. We don�t 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. I�m 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 I�m 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 don�t 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 don�t
know if it is for total health care or for the whole State or what it
was for. That�s 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. Children�s 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 couldn�t 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 couldn�t 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 couldn�t 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 don�t 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, today�s 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 can�t 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 won�t
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 don�t 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 don�t 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 can�t 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 that�s 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 doctors� 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 can�t swear to that.
Mr. Burgess. There are millions of dollars available, and again, I
just can�t understand why those funds couldn�t 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
I�m 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, I�m 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 don�t 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 didn�t 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 I�m 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 profession�s 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 today�s 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. We�re 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, you�re 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, ma�am.
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, ma�am.
Ms. DeGette. You can�t, over the long run, become a Charity-type
hospital, that�s not your hospital�s 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. That�s 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 can�t 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, ma�am.
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 doesn�t qualify as the
standard of care because it doesn�t 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 can�t 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 don�t 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. It�s 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 don�t
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? I�m 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 I�m going to do. I�ll 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, I�m 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, it�s a mess, Government is too bureaucratic,
nobody can respond to this, da-da-da, then we don�t 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?
Let�s 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 �95, 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. That�s the kind of information that is helpful to us.
Let�s 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 I�m 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 don�t 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. I�m 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 didn�t 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 don�t 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 can�t 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 Jimmy�s, 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, I�m 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. HHS�s
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 Department�s 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 storm�s 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 Department�s
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 Nation�s 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, HRSA�s 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 State�s
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 Secretary�s 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
General�s 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 Children�s 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 storm�s 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 Department�s
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 nation�s 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. �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 re-establishing
communications with healthcare partners.
�In the case of Katrina, HRSA�s Emergency Systems for Advance
�Registration of Volunteer Health Professionals (ESAR-VHP) program
�began working shortly after the hurricane made landfall.� The
�ESAR-VHP 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, these 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 on-line 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
�State's 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 (CC):
Supported a Secretary�s 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 General�s 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 Children�s 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
Agency�s 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
Children�s 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 program�s 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 Medicare�s
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 facility�s 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 hospital�s
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 facility�s 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 patient�s 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 patient�s 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 hospital�s control
(e.g., a flood, fire, or earthquake).
For most hospitals, the exception payments for extraordinary circumstances
are based on 85 percent of Medicare�s 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 physician�s 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 Children�s 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 state�s 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 patient�s agreement to speak with family members or friends
or to honor a patient�s 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 hospitals� 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 anybody�s measurements. We evacuated
120 premature and newborn babies from New Orleans hospitals to Baton
Rouge Women�s 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 I�m 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 didn�t 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 wouldn�t 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 people�s 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, I�m 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
haven�t 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? Nobody�s 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, that�s 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, that�s a quick summary of what I have to say. I�m 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 Woman�s 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. Patrick�s 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 Care�s 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, I�m going to ask you a question that I�m 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. I�m 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, I�m not sure there is a problem. I have no doubt
that this particular waiver is being processed in an expedited
fashion. I�m 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 it�s 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 don�t 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, I�m 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 I�m 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, it�s 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). I�m 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 I�m 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 don�t 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 I�m 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
doesn�t 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 hasn�t 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 don�t 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 don�t 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 don�t.
Mr. Stupak. Well, how did you get the facts for the statement and your
testimony, then, if you don�t know of anyone who received them?
Dr. Agwunobi. The impression, if I may, in New Orleans--I don�t know,
but I do know for a fact that this waiver was (inaudible) allowing
providers to take advantage of it. What I�m 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 didn�t receive any, and you don�t--you saying
that people have been offered the opportunity just doesn�t jive. It
just doesn�t--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. I�m 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 don�t 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. I�m not sure if this particular provision would apply to
them. I can check for you, sir.
Mr. Stupak. If you don�t 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 don�t 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 wouldn�t think that HHS would want a witness who couldn�t
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 don�t.
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 don�t 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. I�m 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. That�s 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 I�m asking--like about the vision--
those were in letters of December 15 and September 6. I�m asking you
now because we still haven�t 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. I�m 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 doesn�t know that. It is his
responsibility to protect the Federal government from liability,
because they are going to be practicing under the Federal government�s
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 people�s 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 it�s 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, that�s what it�s 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 we�ve 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 don�t understand why we don�t 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 don�t 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
someone�s account, I don�t even know if it�s drawing interest.
On the evacuation aspect, and this is something I didn�t bring up to the
other panel, because I don�t even know if it�s 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 Charity�s 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 that�s 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 don�t
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 couldn�t do anything because you didn�t know
about that waiver," or "It didn�t 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 I�m 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 didn�t arrive until January 12, I�m 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 we�ve 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 don�t 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 FEMA�s--who, by the way, I�m 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. There�s been different amounts that have been told to me:
$300 million, $400 million that�s 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 don�t 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 Florida�s 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
doesn�t 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 can�t 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 don�t leave, and we
can�t figure out how to do that.
Ms. Schakowsky. I met with one of those doctors this morning who said
he is starting over; they�re 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, I�m assuming, have come through, they have been able to transfer
their people within their own system. That�s 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 don�t know all of these acronyms and letters, and I�m in
Congress; and how people sitting in the midst of a catastrophes would
know--so I think I�m 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 didn�t mean to imply that. The premise was
I�m not sure if there is a problem with the process. I�m 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 wasn�t 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 don�t 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 letter�s 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 "We�ve received your letter and we�re working on
it and here�s when you can expect it."
That�s 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 doesn�t want to give concretes. I�m sure if we
were to give you the pen, as I offered to the panel previously, and
said, put a line through things that don�t work, tell us what doesn�t
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 that�s 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 wasn�t 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, I�m 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 wasn�t 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 I�m 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? I�m 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 I�m 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
don�t 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 didn�t know that was not a good
plan.
Getting it changed or funded when it has been there for all these years,
that�s 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 wasn�t here this morning with our other
guides, Congressman Jindal and Congressman Melancon. So, we�d 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, I�m
grateful for the committee�s 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 don�t 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. You�ve been generous with your time: ten days for questions
and 30 days for answers. That�s 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.]