[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
POST KATRINA HEALTH CARE: CONTINUING CONCERNS AND IMMEDIATE NEEDS IN
THE NEW ORLEANS REGION
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
MARCH 13, 2007
__________
Serial No. 110-17
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
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COMMITTEE ON ENERGY AND COMMERCE
JOHN D. DINGELL, Michigan, Chairman
HENRY A. WAXMAN, California JOE BARTON, Texas
EDWARD J. MARKEY, Massachusetts Ranking Member
RICK BOUCHER, Virginia RALPH M. HALL, Texas
EDOLPHUS TOWNS, New York J. DENNIS HASTERT, Illinois
FRANK PALLONE, Jr., New Jersey FRED UPTON, Michigan
BART GORDON, Tennessee CLIFF STEARNS, Florida
BOBBY L. RUSH, Illinois NATHAN DEAL, Georgia
ANNA G. ESHOO, California ED WHITFIELD, Kentucky
BART STUPAK, Michigan BARBARA CUBIN, Wyoming
ELIOT L. ENGEL, New York JOHN SHIMKUS, Illinois
ALBERT R. WYNN, Maryland HEATHER WILSON, New Mexico
GENE GREEN, Texas JOHN B. SHADEGG, Arizona
DIANA DeGETTE, Colorado CHARLES W. ``CHIP'' PICKERING,
Vice Chairman Mississippi
LOIS CAPPS, California VITO FOSSELLA, New York
MIKE DOYLE, Pennsylvania STEVE BUYER, Indiana
JANE HARMAN, California GEORGE RADANOVICH, California
TOM ALLEN, Maine JOSEPH R. PITTS, Pennsylvania
JAN SCHAKOWSKY, Illinois MARY BONO, California
HILDA L. SOLIS, California GREG WALDEN, Oregon
CHARLES A. GONZALEZ, Texas LEE TERRY, Nebraska
JAY INSLEE, Washington MIKE FERGUSON, New Jersey
TAMMY BALDWIN, Wisconsin MIKE ROGERS, Michigan
MIKE ROSS, Arkansas SUE WILKINS MYRICK, North Carolina
DARLENE HOOLEY, Oregon JOHN SULLIVAN, Oklahoma
ANTHONY D. WEINER, New York TIM MURPHY, Pennsylvania
JIM MATHESON, Utah MICHAEL C. BURGESS, Texas
G.K. BUTTERFIELD, North Carolina MARSHA BLACKBURN, Tennessee
CHARLIE MELANCON, Louisiana
JOHN BARROW, Georgia
BARON P. HILL, Indiana
______
Professional Staff
Dennis B. Fitzgibbons, Chief of Staff
Gregg A. Rothschild, Chief Counsel
Sharon E. Davis, Chief Clerk
Bud Albright, Minority Staff Director
______
Subcommittee on Oversight and Investigations
BART STUPAK, Michigan, Chairman
DIANA DeGETTE, Colorado ED WHITFIELD, Kentucky
CHARLIE MELANCON, Louisiana Ranking Member
Vice Chairman GREG WALDEN, Oregon
HENRY A. WAXMAN, California MIKE FERGUSON, New Jersey
GENE GREEN, Texas TIM MURPHY, Pennsylvania
MIKE DOYLE, Pennsylvania MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois MARSHA BLACKBURN, Tennessee
JAY INSLEE, Washington JOE BARTON, Texas, (ex officio)
JOHN D. DINGELL, Michigan, (ex
officio)
(ii)
C O N T E N T S
----------
Page
Barton, Hon. Joe, a Representative in Congress from the State of
Texas, prepared statement...................................... 9
Burgess, Hon. Michael C., a Representative in Congress from the
State of Texas, opening statement.............................. 16
DeGette, Hon. Diana, a Representative in Congress from the State
of Colorado, opening statement................................. 6
Dingell, Hon. John D., a Representative in Congress from the
State of Michigan, opening statement........................... 18
Green, Hon. Gene, a Representative in Congress from the State of
Texas, opening statement....................................... 16
Jefferson, Hon. William J., a Representative in Congress from the
State of Louisiana, prepared statement......................... 12
Melancon, Hon. Charlie, a Representative in Congress from the
State of Louisiana, opening statement.......................... 15
Stupak, Hon. Bart, a Representative in Congress from the State of
Michigan, opening statement.................................... 1
Whitfield, Hon. Ed, a Representative in Congress from the
Commonwealth of Kentucky, opening statement.................... 5
Witnesses
Bertucci, Bryan, M.D., coroner/family physician, St. Bernard
Health Center, Chalmette, LA................................... 27
Prepared statement........................................... 129
Cerise, Fred, M.D., M.P.H., secretary, Louisiana Department of
Health and Hospitals, Baton Rouge, LA.......................... 103
Prepared statement........................................... 148
DeSalvo, Karen, M.D., executive director, Tulane University
Community Health Center at Covenant House, New Orleans, LA..... 29
Prepared statement........................................... 130
Answers to submitted questions............................... 136
Erwin, Donald T., M.D., president and chief executive officer,
St. Thomas Community Health Center, New Orleans, LA............ 32
Prepared statement........................................... 138
Answers to submitted questions............................... 144
Fontenot, Cathi, M.D., medical director, Medical Center of
Louisiana at New Orleans, New Orleans, LA...................... 25
Prepared statement........................................... 154
Franklin, Evangeline R., M.D., director of Clinical Services and
Employee Health, City of New Orleans Health Department, New
Orleans, LA.................................................... 3
Prepared statement........................................... 169
Hirsch, Leslie D., president and chief executive officer, Touro
Infirmary, New Orleans, LA..................................... 74
Prepared statement........................................... 183
Koehl, Thomas, director, Operation Blessing Disaster Relief
Medical Center, New Orleans, LA................................ 23
Prepared statement........................................... 156
Lynch, Robert, M.D., director, South Central Veterans Affairs
Health Care, Jackson, MS....................................... 99
Prepared statement........................................... 157
Answers to submitted questions............................... 161
Miller, Alan, Ph.D., M.D., interim senior vice president for
health sciences, Tulane University Health Sciences Center, New
Orleans, LA.................................................... 66
Prepared statement........................................... 164
Muller, A. Gary, president and chief executive officer, West
Jefferson Medical Center Marrero, LA........................... 67
Prepared statement........................................... 167
Norwalk, Leslie, acting administrator, Centers for Medicare and
Medicaid Services, Washington, DC.............................. 97
Prepared statement........................................... 198
Quinlan, Patrick, M.D., chief executive officer, Ochsner Health
System, New Orleans, LA........................................ 69
Prepared statement........................................... 171
Rowland, Diane, executive vice president, the Henry J. Kaiser
Family Foundation, Washington, DC.............................. 21
Prepared statement........................................... 210
Answers to submitted questions............................... 231
Smithburg, Donald R., executive vice president, Louisiana State
University, chief executive officer, Health Care Services
Division, Baton Rouge, LA...................................... 72
Prepared statement........................................... 176
Answer to submitted question................................. 181
Stephens, Kevin U., Sr., M.D., J.D., director, city of New
Orleans Health Department, New Orleans, LA..................... 105
Prepared statement........................................... 173
Wiltz, Gary, M.D., chairperson, Region 3 Consortium Franklin, LA. 37
Prepared statement........................................... 233
Answers to submitted questions............................... 246
POST KATRINA HEALTH CARE: CONTINUING CONCERNS AND IMMEDIATE NEEDS IN
THE NEW ORLEANS REGION
----------
TUESDAY, MARCH 13, 2007
House of Representatives,
Subcommittee on Oversight
and Investigations,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 9:30 a.m., in
room 2123 of the Rayburn House Office Building, Hon. Bart
Stupak (chairman of the subcommittee) presiding.
Members present: Representatives Stupak, DeGette, Green,
Inslee, Dingell [ex officio], Whitfield, Walden, Ferguson,
Burgess, Barton [ex officio], and Blackburn.
Staff present: John F. Sopko, Christopher Knauer, Kristine
Blackwood, Scott P. Schloegel, Rachel Bleshman, Lauren
Bloomberg, Alan Slobodin, Peter Spencer, and Krista Carpenter.
OPENING STATEMENT OF HON. BART STUPAK, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MICHIGAN
Mr. Stupak. I will call this hearing to order.
Today we have the hearing on Post Katrina Heath Care:
Continuing Concerns and Immediate Needs in the New Orleans
Area.
It has now been over a year-and-a-half since Hurricane
Katrina touched land on August 29, 2005. Nearly a year ago,
this subcommittee held a hearing in New Orleans to examine
public health care conditions in the region. What we found then
was a system overwhelmed with far more patient demand than
capacity. Since that time this committee has continued to
monitor and assess the ongoing health care needs faced by those
in the New Orleans region.
A few weeks ago, our majority and minority committee staff
returned from the area to report on where health care stands
today. Unfortunately, what our staffs found is that much of the
region's health care structure still remains crippled and major
problems remain unresolved. In the four worst-hit parishes of
Orleans, Plaquemines, Jefferson, and St. Bernard, the loss of
hundreds of thousands of homes and the closure of many health
care facilities displaced thousands of physicians, mental
health providers, nurses, dentists, obstetricians, lab
technicians, and other allied health professionals.
While estimates are that approximately half of the city's
former residents have returned, it appears that many of those
previously employed in the health care sector have found work
elsewhere and may not return. Many specialists and support
staff are in high demand in other parts of the country. This
demand continues to place significant pressure on New Orleans'
outpatient clinics and hospitals to attract needed medical
personnel. At the same time, the region has experienced an
influx of construction workers and day laborers who often lack
insurance.
Key hospital facilities remain destroyed or closed. The
flagship hospital for the State-run public health system in
downtown New Orleans was known as Big Charity. Big Charity was
the predominant source of healthcare for the large percentage
of poor and uninsured. It will never reopen in the old
building, and a path to building a new hospital is littered
with controversy and obstacles. In addition, privately owned
Methodist Hospital and Chalmette Medical Center, which provided
hospital services for residents east of the city, are closed.
[Slide shown.]
This is what these two hospitals look like today. We have
one back here. Here we go. At Chalmette, we got what, about
four of them?
[Slide shown.]
That is the Wal-Mart parking lot. You can see the trailers
that are right there. We are providing some health care right
now.
[Slide shown.]
And that is Methodist Hospital. There is a fence around it.
It is not open for business but there is a fence around. It is
hard to see. If that was a real hospital, you would see more
than just two cars around there. Next facility? That is it? OK.
Hospitals that were able to remain open during the storms
or have since reopened continue to struggle with critical
staffing shortages, rapidly spiraling costs, and inadequate or
delayed reimbursement. These challenges are compounded as they
treat New Orleans' poor and uninsured who were previously
provided for by Big Charity.
Many of today's witnesses have made tremendous personal
sacrifice to help their community and its medical
infrastructure recover while they cope with the loss of their
own homes and neighborhoods. Along the way they forged many new
and innovative partnerships. Their courage and heroism is an
inspiration to us all. It is clear, however, that there is so
much more to be done and soon.
Our hearing today will focus on what the health care
providers believe are the most urgent health care issues that
need to be addressed in the short term. For example, as debate
continues about when, where, how big, or even whether to
rebuild a charity hospital in New Orleans, there is no
consensus on how to cost-effectively deal with the growing
number of uninsured and underinsured patients now flowing into
the region. Many who were once able to rely on Charity Hospital
must now turn to either University Hospital, which has only 100
beds, or travel to other parts of the State for treatment at
one of the State's other public hospitals. Traveling for health
care is impractical for many residents, particularly given the
transportation problem still plaguing the State. Others are
seen by the region's private hospitals. However, aside from
loading an uninsured with complications from diabetes into an
ambulance and delivering him or her to an emergency room, the
most expensive avenue of treatment, there is no way to allow an
uninsured patient to easily access private care.
Because Louisiana State law has directed that the bulk of
the Medicaid disproportionate share, DSH, dollars go to the
State Public Health Care System, significant challenges remain
about how to allow the uninsured access to existing capacity
while providing fair compensation to the doctors and hospitals
that provide the care.
Given that Big Charity is no longer viable and won't be for
at least 5 to 7 years, access to health care for the uninsured
and poor must be resolved. And while we must find a way to
compensate those private hospitals that are currently providing
care, we must also ensure that private hospitals shoulder the
full spectrum of the uncompensated care patients, not just the
healthiest. All this must be done in a way that is reasonably
fair to both the institution and the taxpayers.
Another area that must be addressed immediately involves
the many outpatient clinics now providing critical safety-net
care. Many of these clinics, including those that make up the
PATH network, are seeing patients that otherwise would have
little or no access to healthcare services. These clinics are
filling critical health care needs where there was once a
public hospital and clinic system. They also provide ambulatory
and preventative care that would otherwise require an expensive
trip to the emergency room.
Nonetheless, more needs to be done to integrate these
important health care providers into the existing hospital
structure and reimbursement structure. For example, if someone
with complications from diabetes shows up at a small primary
care clinic, there is no formal way to refer him or her to the
surrounding hospitals, particularly a private hospital other
than placing the patient in an ambulance and sending him to the
emergency room. If the patient is under- or uninsured, this
makes the effort even more daunting. As these clinics are often
working on small budgets comprised of donations and small
grants, a formal mechanism to reimburse them for the care they
provide must be explored. These clinics will play a significant
role in providing care for the region's poor for the
foreseeable future.
Another area that needs immediate attention is the State's
ability to train its own health care providers. The New Orleans
region was a significant training center for the State's future
doctors, nurses, and other health care practitioners. Since
both of the primary teaching facilities, the Veterans Hospital
and Big Charity, were destroyed, the region's two medical
schools, LSU and Tulane, have struggled to keep their teaching
programs together. And while LSU and Tulane have managed to
hold many of their programs together by placing their students
around the region in other hospitals, this stop-gap measure
will only last so long.
As reported to this committee by officials from both
medical schools, key programs have already lost accreditation
and others are now threatened. Shoring up the region's medical
schools and teaching facilities is a significant urgency, and
this alone will be a daunting task. A solid plan must be
developed for LSU and Tulane so they can continue to train
much-needed health care professionals.
I want to talk for a minute here about the model that has
been used so far to attempt to address some of the rather
daunting health care challenges that have faced the region
post-Katrina.
Last year the Secretary of Health and Human Services asked
the State to come up with a plan to fix the region's health
care infrastructure including some of the issues I just raised.
That process became known what is generally referred to as the
Collaborative, and it is a very important chapter in the State
and Federal Government's response to the region's post-Katrina
health care needs.
The Collaborative plan brought together a vast array of
stakeholders, public and private, State and local, to find ways
to restructure health care delivery system for the area's most
affected by the storm. This area referred to as region 1
encompass Orleans, Jefferson, St. Bernard, and Plaquemines
Parish. While many of the participants in the Collaborative had
significant differences of opinion, they worked hard to achieve
consensus on some major points.
Last October the Governor submitted the Collaborative plan
to the Department of Health and Human Services. What came back
from HHS just a few weeks ago appears to be a proposal that is
very different in both size and scope than what the State sent
to HHS. Instead of working on the various points of consensus
and rolling out a pilot plan for region 1, HHS answered with a
plan to replace Louisiana's statewide public health hospital
system with what appears to be an insurance model. Putting
aside the various HHS plans or one view on the State's public
health care system, HHS's plan may simply be too ambitious at
this point in the recovery process. Applying just some of the
concepts of the Collaborative merely to region 1 would be
difficult enough, but having Louisiana implement a sweeping,
statewide redesign of its complex, publicly funded hospital
system, may simply be unworkable in the current environment.
While HHS may have good intentions in this effort, much smaller
bites of the apple must be taken if we are going to provide
access to health care in New Orleans.
Unfortunately, the State and Federal Government now appear
to be at an impasse. Instead of breaking off pieces of a
complex health care system and forging ahead with ways to solve
each piece, I fear that the State and Federal Government will
become locked in a colossal fight of dooming spread sheets and
armies of actuaries. Answering the question whether HHS
proposal can work or would instead obliterate the safety net
for hundreds and thousands of low-income residents across the
whole State as Louisiana's Secretary of Health and Hospitals
now suggest seems less important in the amount of time and
energy that will be expended in this fight. Perhaps rather than
one-size-fits-all plan, the Secretaries of Health for both the
State and Federal Government should attempt to address smaller
portions of this problem and provide health care of all the
citizens in region 1.
There is an old African proverb that goes something like
this. When elephants fight, it is the grass that suffers. I am
afraid that is where New Orleans region finds itself with
health care today. Tremendous energy is already gone into
attempting to solve the health care needs of the region.
My admiration goes out to all the witnesses that are in
this room today, those representing small clinics, those
representing public and private hospitals, and those
representing both the State of Louisiana and the Federal
Government. Each of you has greatly contributed to keeping the
region alive through your creativity and your countless hours
of service. Nonetheless, I fear if you do not find new ways to
work together on these issues soon, the health care situation
in the region may grow worse.
Let me be clear as to why we are here today. The hearing is
not about pointing fingers, nor is it about attacking one
another. I understand that many of you have very valid
philosophical differences about how to get the job done; but
frankly, you all work too hard to allow this ongoing effort to
be balled into a bigger exercise of blaming one another for
poor choices. Instead, I challenge you to use today's hearing
as the opportunity to seek common ground.
I am looking forward to hearing from each of you about what
problems you think need immediate focus and some proposals for
ways we might be able to work together, the Congress, the
executive branch, State and local government, private and
public providers, to address the health care needs of your
region. Too many lives are counting on your collective efforts,
and I intend to do my best to use this committee to play our
small part.
Let me conclude by again thanking every witness that will
be testifying here today. Many of you have taken great expense
to be here and have left your practices of providing needed
health care to the region to be here. Your input and
willingness to be here is boldly commendable and appreciated by
us and the people in the New Orleans region.
Let me also thank my colleagues on the other side of the
aisle. Mr. Whitfield, you and many of the colleagues on both
sides of the dais have been particularly gracious with your
time and attention to this matter. Moreover, I want to thank
our staffs for their excellent input they have provided into
this inquiry. I look forward to working with all of you as we
continue to stay involved in this critical matter.
With that, I now yield to my good friend from Kentucky,
Mr. Whitfield; and I would just remind our witnesses, we have
four hearings this week in Energy and Commerce Committee. Mr.
Dingell is overworking us and underpaying us, but Members will
be coming in and out. So you will be seeing people coming in
and out all day.
And with that, Mr. Whitfield, great to be with you for your
opening statement, sir.
OPENING STATEMENT OF HON. ED WHITFIELD, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF KENTUCKY
Mr. Whitfield. Chairman Stupak, thank you. And I also want
to thank those witnesses who have come from the New Orleans
area to testify today on this important topic. I would suspect
that if there is any group that has been overworked and
underpaid over the last few years it is this panel of
witnesses, in fact, all three panel of witnesses; and we
genuinely appreciate the great effort that you all continue to
make in the New Orleans area.
I remember January 2006 this subcommittee came to New
Orleans and held a hearing on the state of health care delivery
post-Katrina. And we know as I said earlier you have met many
challenges that have been extremely difficult, and all of us
have been amazed at the progress that you have been able to
make in the New Orleans area, but we also understand that you
have a long way to go. And from the testimony that I have read
that will be given today, access to care continues to be
limited with critical shortages of mental health, long-term
care, and certain surgical services, private and community
hospitals which stepped up to cover the care gaps created after
the various hospital closures have been operating at a deficit
under existing apparently inflexible State and Federal
financing system, physician and other staff shortages, coupled
with ongoing funding obstacle for these providers impede
further expansion of health care options. A budding community
health center system which I believe has great promise and
maybe can even transform access to and the quality of health
care, not only in New Orleans but around the country is one of
the bright, shining spots I see.
Failure so far to shore up the system raises a risk of a
disintegration of the graduate medical education system in New
Orleans, historically the source of most of the State's nurses
and physicians. And meanwhile, hospitals and other health
providers, local, State, and Federal health officials appear to
be at an impasse over both short- and long-term plans for the
region at this critical juncture.
Obviously those of us on this subcommittee do not have the
answers. Hopefully listening to your testimony we can come up
with some short-term solutions to maximize the opportunity for
a great health care delivery system in the New Orleans area.
And as Chairman Stupak said, the only purpose of this
hearing is to try to come up with some short-term answers to
get the train back on the track for lack of a better term.
So I want to thank all of you for being here. We look
forward to your testimony, and we look forward to working with
you to help solve the significant obstacles that still stand in
your path.
I yield back the balance of my time.
Mr. Stupak. I thank the ranking member. Next, Ms. DeGette
from Colorado, 5 minutes for opening statement.
OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF COLORADO
Ms. DeGette. Thank you very much Mr. Chairman, and thank
you in the whole committee for the continuing efforts to keep
this issue of Hurricane Katrina on top of our agenda.
While the hurricane now was a year-and-a-half ago and while
the country poured out its heart to those affected by the storm
right after it was hit, attention has now been diverted to
other issues. But for this committee and for the sake of those
committed to rebuilding New Orleans the way it was, we have a
duty to continue to engage on this issue.
I have been down to New Orleans twice looking at health
care issues. In January 2006, this subcommittee looked at the
damage put to the health care infrastructure of the city of New
Orleans. Put simply, and as we saw from some of the slides, the
media did not do it justice. The interior of Charity Hospital,
which was once the keystone of the city's health care safety
net, was completely destroyed. Medical records were rotting,
mold was growing on the wall, medical equipment was strewn
everywhere, and I can honestly say I have never seen anything
like it.
During our field hearing the next day, I was gratified to
hear about the efforts of some of the city's private hospitals
to provide care to those who would otherwise seek aid at
Charity. These hospitals, having suffered less damage and
having insurance, were able to return to service much more
quickly, and they stepped up to fill a need. The next time
after that I was in New Orleans, I found that these hospitals
were still fulfilling the need; but as that turned out, of
course, the role these hospitals played was only temporary.
During the first hearing, I asked the panel of the private
hospitals if their long-term business plans included providing
care to the population previously served by Charity; and
everybody got a look of shock on their face and said, no, that
was not in their business plan for assuming the care of
Charity's patients in the long term.
So Mr. Chairman, as we examine plans for the longer-term
revitalization of the health care infrastructure of New
Orleans, I look forward to hearing from our witnesses about
putting in place a health care system that is permanently going
to provide for health care for indigent patients. And frankly,
while we are looking at long-term plans for New Orleans, we
can't overlook those who are in need of health care services
right now. Right now we have a patchwork and we have in our
notebooks--and I know there is a map over there of the ad hoc
system that has grown up in New Orleans. We need a thoughtful,
long-term approach to deal with this. Otherwise, there will be
nobody in place in 10 years to serve once the grand redesign
has been put into place.
Now, frankly, the city faces the chicken and egg problem
because medical professionals are needed in the community to
provide care to those rebuilding the city while those medical
professionals need a place to live and get paid for the
services they are providing.
I want to hear from our witnesses today about how we might
encourage physicians and nurses to return to the city and
provide health services as they once did. Otherwise, the best
reimbursement system will fail.
After Hurricane Katrina hit New Orleans, the response from
the Federal, State, and local governments was at best an
uncoordinated mess. Public servants from all levels of
government worked courageously to meet health care needs of
thousands throughout the city. But policymakers failed to
maximize resources to address the immediate needs of patients
and did not plan for how to bring the health care system back
on line quickly. Instead of fixing the problem now, we more
often see our elected officials and appointees squabbling.
And so as the chairman said, the time has come for all of
us to put aside our differences, roll up our sleeves, and
develop some consensus solutions. The people of New Orleans
have suffered greatly, and it is our job to make their lives
better.
One thing I just want to mention, I am deeply concerned and
have been all along about what we do about establishing a long-
term level one trauma center in New Orleans because the last
few times I was down there they didn't have one. Now we have
one operating, but as I understand it has only 100 beds. This
will not suffice for the long-term future, and we are going to
need to grapple with how we come up with a cohesive health care
system in New Orleans that serves all the patients that need to
be served in a rapid and technologically advanced way.
So I hope our witnesses have some ideas on this. I want to
thank you again, Mr. Chairman, for holding this next in a
continuing series of hearings, and I yield back.
Mr. Stupak. I thank the gentlewoman. Next turn to Mr.
Barton, ranking member of the committee. Mr. Barton, I
appreciate your continued interest in oversight investigations.
I know you were a chair a one time, and I certainly appreciate
your continued interest.
Mr. Barton. Thank you. Thank you, Mr. Chairman. I will
submit a written statement. For the record, we support this
hearing. We had a field hearing on this issue in New Orleans in
the last Congress. We plan to continue to work on a bipartisan
basis.
I will say I think you have set a record for most witnesses
at one oversight hearing. We have 17 and I believe that beats
the record of the last Congress, but we will get to the bottom
of it.
I yield back.
[The prepared statement of Mr. Barton follows:]
[GRAPHIC] [TIFF OMITTED] 36572.001
[GRAPHIC] [TIFF OMITTED] 36572.002
Mr. Stupak. It was not the number of witnesses, it is the
number of problems we are facing.
Next we will go to Mr. Melancon from Louisiana.
Mr. Melancon. Thank you, Mr. Chairman. If I could, I would
like to request by unanimous consent a statement from
Congressman Jefferson and one from Louisiana Recovery Authority
be added into the record?
Mr. Stupak. Without objection it will be added.
Mr. Melancon. Thank you, sir.
[The prepared statement of Mr. Jefferson follows:]
[GRAPHIC] [TIFF OMITTED] 36572.003
[GRAPHIC] [TIFF OMITTED] 36572.004
[GRAPHIC] [TIFF OMITTED] 36572.005
OPENING STATEMENT OF HON. CHARLIE MELANCON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF LOUISIANA
Mr. Melancon. First, I would like to welcome all witnesses
today and thank them for the time they have taken to come to
testify. I would also like to thank you, Mr. Chairman, for
dedicating the committee's time and the resources to the Gulf
Coast health care crisis.
I am glad to see Congress take another step towards living
up to its commitments that we have made in August 2006 on the
Katrina-Rita Task Force Trip to the Gulf Coast.
A year-and-a-half has passed since Hurricane Katrina made
landfall, and south Louisiana's health care system remains in
crisis. There is no doubt that our health care system faces
serious long-term challenges, but today we are here to focus
our attention on the immediate needs. Our objectives are
simple. We want to help enhance the region's capacity to take
care of the patients' immediate needs and want to help the
region demonstrate a level of care and quality that will bring
our people back.
Achieving these objectives requires us to understand what
resources are needed. Today's testimony will help the committee
to grasp and meet those needs. To explain the situation in
detail is outside the scope of this opening statement, but just
to give you some examples, our primary caregivers are few and
far between, hospitals are filled to capacity with many who
have not received basic primary care in over a year, the number
of uninsured has hit an all-time high. In a recent Times-
Picayune article, the average wait time in the emergency room
at Touro Infirmary was 6 to 8 hours. That is about the same
time it takes to drive from New Orleans to Houston or Atlanta.
In Chalmette, Louisiana, there isn't even a hospital to wait
in; rather people line up outside tents in front of the Wal-
Mart or what used to be the Wal-Mart to receive health care
services that are still being provided.
I hope that today's hearings help us identify our short-
term challenges. I also want to use this opportunity for all
stakeholders in the region to sit down together and talk with
each other, rather than at each other. I want to remain focused
on finding common ground. Everyone in this room has been called
to serve the people, either through medicine or public service.
We should remain focused on the common ground of serving the
people as we continue our conversations over the next several
months.
I want to again thank the witnesses who have come here
today, and thank you for your continued and dedicated service
in providing good health care to the people of the disaster-
ridden area. And again, I would like to thank Chairman Stupak
for his persistence and his tenacity. He has given me assurance
that this subcommittee will revisit the Gulf Coast health care
crisis as many times as it may be needed until we find
solutions.
I look forward to working with you to resolve the important
issues and get our health care system back running in a way
that it should be.
Thank you, Mr. Chairman. I yield back for time.
Mr. Stupak. I thank the gentleman. Up next, Mr. Walden.
Mr. Walden. Thank you, Mr. Chairman. I just wanted to
welcome our witnesses. I don't have an opening statement this
morning. I look forward to hearing from them, and I yield back.
Mr. Stupak. Mr. Green from Texas, opening statement?
OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Green. Thank you, Mr. Chairman. I would like to have my
full statement placed into the record and just briefly say that
it continues to shock us. I have a district in Houston, and
knowing what our neighbors in Louisiana and New Orleans have
gone through and to see that the status of the health care
where there are no public hospitals and the number of people
who have a disproportionate share of the private, for-profit
hospitals weren't picking it up, obviously there has to be a
lot of changes in it. And Mr. Chairman, I am glad we are having
this hearing, and hopefully we will follow up with legislation.
I serve on the Health Subcommittee, so I would like to see how
we could deal with it. On a personal note, in Houston after
Katrina or during Katrina, we received over 100,000 Katrina
evacuees, in fact, estimates up to 250,000; and I was so proud
of what our community did on very short notice, the for-profit
hospitals, non-profit, plus our public hospitals coming
together and working side by side when the rest of the year
they compete every day but it worked.
I have to admit, Mr. Chairman, we got some commitments from
the Federal Government because Texas is not known as a high
expense Medicaid State. In fact, our match is much more than
what Louisiana was. We did get Federalized the State/local
match. The problem is there were lots of commitments made on
that Labor Day of 2005 but it didn't work out. It is
frustrating.
And so I hope our Oversight Committee can bring to life
what we need to do, plus look at legislative solutions so when
this happens again, because this year it could be Houston where
we may be going to New Orleans, in all honesty. I hope that is
not the case, but looking at your infrastructure, we still have
to build a lot there.
But there but for the grace of God goes any of us who live
along the Gulf Coast or the east coast of the United States, so
I am glad you are having this oversight. Thank you.
Mr. Stupak. Thank you, Mr. Green.
Next I go to Mr. Burgess from Texas. Mr. Burgess, opening
statement?
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. Thank you, Mr. Chairman. Again, I thank you
for calling this hearing today.
We have all read a lot about what happened down in the Gulf
Coast. We all have questions about preparedness, we all have
questions about the adequacy of the response. Most explosive
have been the issues surrounding the three catastrophic events
that occurred the day that Katrina hit the Gulf Coast. We had
the wind damage, you had damage from the surge down in
Plaquemines and Port Chalmette, and then the levee breach that
affected both West Jefferson and the city of New Orleans
itself.
Responsibility rests at every level of government. The time
has certainly passed for fixing blame; but today in this room,
in this committee we must focus on not only what destroyed the
health care community, the extent to which it has recovered and
can recover in the future, and how to prevent this from ever
happening again.
In October 2005 I visited both Orleans and Jefferson
Parishes. The people there were very kind to me and welcome me
into their community. It wasn't really an official visit, but I
wanted to see for myself the physical damage to the buildings
and the property; and most important to me is what was
happening in the level of the local practitioner in the health
care community.
Let me put my opening statement into three principles, the
most important is having a plan in place in case a disaster
threatens. The case in point, I think the gentle lady from
Colorado already addressed, the difference between HCA's
hospital implementation of an emergency plan and essentially
the lack of a plan across the street at Charity Hospital.
Across the street from each other the differences and outcome
were astronomical. One stands today, and today as we sit here
in this committee we wonder if one of the venerable old
institutions in medicine will ever be what it once was again,
Charity Hospital.
[Slide shown.]
There is a slide up there. Actually, this is the correct
slide. The obvious need for electronic medical records. It is
amazing how a small electronic device can keep health records
of thousands of individuals safe from destruction.
[Slide shown.]
This is a photograph from our visit, our field hearing last
January to Charity Hospital. This is the records room; and as
you can see because of the extent of the mold damage and water
damage to those records, very little useful data will be able
to be gleaned about anyone's ongoing medical care.
This committee has the oversight capabilities to encourage
and set regulations to move the use of medical records along,
and I believe we should.
And just parenthetically, Mr. Chairman, I will add that
yesterday I was at Walter Reed Hospital here in Washington and
the same issue came up. We all heard the great things the
Veterans Administration is doing with their electronic medical
records, but apparently the DOD medical records don't
communicate with the VA medical records and that remains a
problem for our soldiers who are on medical hold or are looking
to get out of the military for medical reasons.
Just after Katrina passed, many displaced individuals,
thousands with severe medical illnesses were uprooted and moved
to various places, some to my district in Texas. The Tarrant
County Resource Connection in Ft. Worth where one of my
district offices is located was a recipient for some people who
had to leave New Orleans. We worked with the local American Red
Cross to prepare for the busloads of citizens to arrive. When
they did arrive, many were in quite fragile medical condition.
You can imagine my concern when I got a call from a staff
member who asked me if a lady had a C-section, how soon could
she sleep on the floor. Why do we need to know this? Well, we
have a lady here who had a C-section yesterday, and we don't
have enough cots for her. The really bad part of that story was
at the time, no one had any idea to the hospital to which her
baby was evacuated. It took us several days to ascertain that.
The medical community in north Texas did rise to the
occasion both in Tarrant, Denton, and Dallas Counties and did a
wonderful job with helping people; but the fact is, it should
never have been necessary for them to respond in such an
emergent fashion.
The final principle is that I want to discuss in this
hearing is actually set out a plan of action. We are focusing
on the achievable and the desirable. We have a tendency in
Congress to simply debate problems forever, but this hearing
needs to be about solutions and the follow-through.
Specifically it was well-documented that after Katrina the
medical community in New Orleans was not recovering, the
medical professionals were unable to care for individuals, they
lacked funding and resources to actually assist those in need.
The disaster medical assistance teams flown in from around the
country did a great job. The reality was if they hadn't been
there to set up on the grounds of some of the hospitals, the
waits for emergency treatment were in excess of 24 hours,
sometimes for something as minor as an ankle sprain or as major
as a heart attack. Any major disaster, a bus crash or fire that
might affect five or more people, would greatly benefit from a
level one trauma center; and New Orleans lost their trauma
center. Now that means if a bus crash occurs, the lives of many
more could be jeopardized where they would have to go over 2
hours to the nearest trauma center.
The effects are ongoing, Mr. Chairman. We cannot continue
to just debate and point fingers. This committee must make
specific goals to instigate change. We must also accept
responsibility to continue our oversight. I would recommend
quarterly hearings on this subject and at least once a year in
the city of New Orleans itself.
As we begin today's hearing, I am hopeful that we will all
keep in mind that this is about helping to mitigate future
disasters and ensuring that the best health care is available
to those in the greatest need, even in the gravest of times.
Thank you, Mr. Chairman. I will yield back.
Mr. Stupak. I said earlier we have about three or four
hearings this week in committee, that you are overworking us
and underpaying us. But I see you are here with us today.
Thanks for coming.
OPENING STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MICHIGAN
The Chairman. Mr. Chairman, you are most gracious. I want
to commend you for the outstanding job you are doing and also
to thank you for holding a very important hearing here today. I
want to acknowledge also the contributions and hard work on
this hearing made by the distinguished ranking member of this
subcommittee, Mr. Whitfield, as well as that of our friend and
colleague, the ranking member of the full committee, Mr.
Barton.
Nearly 18 months after Hurricane Katrina, major problems
remain on how to care for the region's many residents who are
trying to rebuild their lives or return to their homes. I fear
we are now on the verge of turning the Nation's largest natural
disaster into the Nation's largest man-made disaster. Private
hospitals are bleeding red ink. There is still no agreement on
how to or even if to rebuild Big Charity, the Nation's primary
public hospital.
The Department of Veterans Affairs has proposed to
collaborate with that effort, but now there is disagreement as
to what role they should play and where the new VA hospital
should be located or even if they should remain a partner in
the deal with Charity.
If no one draws a line through the center of the city, it
reveals that there is no functioning hospital which exists east
of that line. Chalmette, east New Orleans, St. Bernard Parish,
all remain without a medical facility. Residents there rely on
a few small overworked and overwhelmed clinics where there are
health care needs. Many nursing homes remain closed. There is
acute shortage of nurses for the entire area. There are
virtually no beds in the region for those needing detox
treatment. Caring for the mentally ill remains exceptionally
challenging as many psychiatrists and other mental health
specialists have left the region. And at best, there are few
beds to house such patients.
Those doctors who are trying to remain in the region often
encounter difficulty in obtaining reimbursements for services
to either patients or hospitals. Many have already left but
others may be soon forced to do likewise because they cannot
afford to remain there because of financial problems.
The situation here then is bleak. It is therefore to the
third panel, the government panel, that I will direct the rest
of my statement.
Without a doubt you have all put significant energy into
trying to solve these problems. Your efforts are appreciated,
especially for the untold hours that you have dedicated to this
cause. Nevertheless, it is clear that things are not working.
Let me provide an example.
Secretary Leavitt asked the State of Louisiana to provide a
plan on how to rebuild the Nation's health care infrastructure.
Though much of the disagreement was encountered, the difficult
decisions were presented and made. The State and its various
stakeholders, public and private, held up their side of the
bargain and they produced a plan.
That plan, known as the Collaborative, was transmitted by
the Governor of Louisiana to Secretary Leavitt on October 20,
2006, about 6 months ago. The State's plan called for a series
of pilot projects in region 1 where the devastated parishes are
located in and around New Orleans. What Secretary Leavitt sent
back is not even a formal plan. It is a loose confederation of
spreadsheets and bullet points. It asks the State to
disassemble its statewide public hospital system and replace it
with some form of insurance program, a most curious
consequence.
There are almost no specifics in the plan, and at least
none are available to the public. There is not even a formal
publication from the Secretary to the Louisiana Governor that
this committee could review, despite the requests of this
committee to obtain such a document; and we will again, at the
appropriate time, ask the Secretary to make such document
available to the committee. The State of Louisiana now counters
that the HHS proposal will not work.
Now, I do not bring these points up to point fingers but to
suggest that we are now facing a deadlock between two very
important players who are needed to solve these problems. If
not fixed quickly, the next 6 months will be spent on dueling
spreadsheets. Simply put, the plan proposed by Secretary
Leavitt, regardless of your opinion of the State's system, is
simply too large of a task to undertake at this time. Even if
adopted, it will not address the immediate problems faced by
patients and the practitioners in this region.
I therefore call on the Secretary of Health and Human
Services and the Louisiana Secretary of Health and Hospitals to
immediately convene a series of meetings to re-energize the
next steps on how to move forward. Both are at an impasse and a
serious one at that. If not corrected, this situation will
jeopardize not only progress that has been made on the ground
but also the future of the region, and I would note that this
committee will be having further hearings to bring the
Secretary and others before us to explain what they are doing
and whether progress has been made as a result of these
hearings today.
Mr. Chairman, I want to congratulate you and commend you
for what you have done today. I suggest that you consider
holding the additional hearings that are needed on this matter.
I believe the committee can and should work with and hold
accountable if necessary the public entities that are
responsible for providing leadership in this important area.
Thank you, Mr. Chairman, I appreciate your courtesy.
Mr. Stupak. I thank the gentleman.
Mr. Whitfield. Mr. Chairman?
Mr. Stupak. Mr. Whitfield.
Mr. Whitfield. Mr. Chairman, Congresswoman Blackburn
officially became a member of the Energy and Commerce Committee
last night, and she will be a member of the Oversight and
Investigation Subcommittee but will not be a member until
Thursday. And she is very much interested in the topic of this
hearing today, so I ask your unanimous consent that she be
allowed to participate in this hearing today.
Mr. Stupak. Hearing no objections, that will be granted.
Mrs. Blackburn will be allowed to participate in this hearing.
She was actually with us in New Orleans a year ago when we had
the hearing, so it is good to have her back.
Earlier today Mr. Melancon asked me to put two statements
in the record. Congressman William J. Jefferson, he is a Member
from the New Orleans area. We will accept that statement. The
other statement, though, on behalf of Louisiana Recovery
Authority we cannot accept. This is oversight investigations.
It would not be subject to any kind of cross-examination or any
type of questioning from this panel, and each group that wants
to put in a statement we cannot accept. It would just clutter
the record. We want to keep ours clear.
If the gentleman wishes to refer to it throughout or if any
Member wishes to see it to refer to it throughout this hearing
today to ask a question to a witness, to pose a question from
it, we will accept it for that purpose only.
With that, we have our first panel up. I ask the panel--
this is an Oversight Investigation Committee as I indicated. It
is tradition here that we swear the witnesses.
[Witnesses sworn.]
The record should reflect all witnesses indicated positive
that they understand they are under oath. They are now under
oath. We will begin with our first opening statement by Ms.
Rowland, recognized for 5 minutes for your opening statement.
STATEMENT OF DIANE ROWLAND, EXECUTIVE VICE PRESIDENT, THE HENRY
J. KAISER FAMILY FOUNDATION, EXECUTIVE DIRECTOR, KAISER
COMMISSION ON MEDICAID AND THE UNINSURED, WASHINGTON, DC
Ms. Rowland. Mr. Chairman, members of the subcommittee, I
am honored to participate today in this important hearing to
assess the state of health care services in New Orleans 18
months after Katrina and hope to help frame some of the issues
before you today.
Louisiana, we need to recall, before Katrina was one of the
poorest States in the Nation with over a quarter of its
residents living in poverty. It ranked at the bottom of most
health statistics in terms of the States of the Union with
higher rates of diabetes, heart disease, AIDS, infant
mortality. It had limited public and private coverage, leaving
one in five of its residents uninsured. But clearly, this was a
State with severe health care needs. It provided for those
needs through a two-tier system, private doctors and hospitals
for the insured and a State-run charity hospital system for the
poor and uninsured, financed largely through Medicaid
disproportionate share hospital payments.
That made care in New Orleans for the poor and the
uninsured hospital-centered and based and Charity the source of
most of the inpatient services, psychiatric services, specialty
care for the low-income population. Katrina and the flooding
that subsequently happened destroyed the infrastructure as well
as the structure for care of the uninsured in New Orleans. You
have all gone through the very many hospitals that had to
close, the loss of the workforce.
We have been doing survey work in New Orleans trying to
understand what the needs of the health care population there
are, and in October 2006 our household interview survey in the
New Orleans area revealed continued high rates of uninsurance,
problems with access to care, and the fact that 90 percent of
our respondents did not feel there were enough services,
hospitals, clinics, medical facilities in the New Orleans area
to meet their needs and that it was one of the most troubling
factors in their decision of whether to return to New Orleans
or to stay in New Orleans.
There are severe challenges to the workforce shortages and
the limited hospital and clinic financing, critical shortages
of mental health services, and psychiatric beds with the
closure of Charity. There is a growing uninsured population,
both as people have lost their job base coverage but also with
the new labor force coming into the city. And there has been
delayed assistance from the Federal Government to support
community-based care and troubling negotiations that continue
over how to rebuild the system.
There are steps, however, that could be taken now to help
restore some of the services to the Louisiana area and to
improve access to care and give residents the confidence they
need to have their health services available.
First and foremost is to maintain the Medicaid and LaSCHIP
coverage, the SCHIP program for children in Louisiana, and
hopefully in your reauthorization of SCHIP, to continue to
provide the funds there so that the children of Louisiana can
get their care. But more importantly, immediately you can raise
the eligibility levels or the State can move to do that, to
provide Medicaid assistance to more of the low-income adults
who currently don't qualify for Medicaid because the income
eligibility level remains set at 20 percent of the Federal
poverty level, or $3,000 a year.
Second, you need to rebuild the capacity in the city.
Health care coverage can help that by putting the dollars into
the providers from the patients as they seek care, but
additional incentive payments are needed to recruit back a
workforce; and you can also look at provisions in the Medicare
statute that would extend the reimbursement for extraordinary
labor costs that can come through the Medicare program to help
improve the financing for the hospital system.
But most importantly as I am sure this panel will tell you,
you need to develop secure financing for the emerging
development of community-based care that can help move the care
out to where the patients are and can help to provide early
access to primary and preventative services that can deal with
the chronic illnesses that face so many of the individuals in
New Orleans.
So in sum, I think you need to really look at how to put
services in place, and financing is a very important piece of
that. There needs to be greater flexibility over the use of the
already-allocated DSH funds, more direct Federal assistance
through the use of the discretionary fund that remain
uncommitted from the Deficit Reduction Act, help build access
to care and to support some of the community development. The
Social Services Block Grant that has been so critical to
extending psychiatric services is about to run out. It could be
extended to provide additional resources there to help rebuild
the capacity to deliver mental health services, and you may
well need to look at supplemental appropriations to provide
more of the on-the-ground services that are required.
As your panelists will tell you today, the needs are real,
the commitment to provide services is extraordinary among those
who have been working in the trenches for so many months to
help restore coverage, but the resources are not there on the
ground to let them do the job they need to do.
I hope that this hearing will help move us forward to
address those deficits and to give the people of New Orleans
the health care services they need and deserve.
Thank you very much, and I will welcome your questions.
[The prepared statement of Ms. Rowland appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you, Ms. Rowland. Mr. Thomas Koehl,
director, Operation Blessing Disaster Relief Medical Center.
Sir, for 5 minutes you are recognized.
Mr. Koehl. Thank you. I would like to show a video first.
Mr. Stupak. Sure.
[Video shown.]
STATEMENT OF THOMAS KOEHL, DIRECTOR, OPERATION BLESSING
DISASTER
Mr. Koehl. My name is Thomas Koehl. I work for Operation
Blessing, a humanitarian relief organization that responds to
both domestic and international disasters.
Among other activities, as you have seen, we provide a free
medical/dental clinic in New Orleans. We presently see 75 to
100 patients a day with a staff of volunteer doctors, nurses,
nurse practitioners, and physicians assistants.
In the past 11 months we have provided health care for
15,000 patients and provided over 25,000 free prescriptions to
these residents of the stricken city.
These residents were pulled from the rooftops, they waded
in water, they spent days sweltering in the heat on highway
overpasses and in the Superdome. They are a never-before-seen
American. Over 100,000 newly made poor, helpless, homeless, and
marginalized. Our task, should we not forget it, yours and
mine, is to relieve their suffering.
When Katrina struck, it washed away their homes, their
jobs, and their health care but did not wash away their high
blood pressure, their diabetes, or their other chronic
illnesses.
The need for health care is so great that at our clinic
every weekday morning at 3:00 to 4:00 in the morning the line
begins. Grandmothers, single mothers with sick children, entire
families waiting in the cold and waiting in the dark for a
health care provider.
The need was so great that as you saw on our video,
Operation Blessing recently partnered with Remote Area Medical,
International Medical Alliance, the New Orleans Health
Department, and the Louisiana Department of Health and
Hospitals to host this medical recovery week.
On the very first morning of this event, I met a man named
Mike in our triage area. He had made his way through the maze
of tents concentrating on staying warm and keeping his place in
line. He was one of hundreds who had arrived in the pre-dawn
hours. I asked Mike when he had arrived. He had gotten in line
at 10 p.m. the night before. I asked him why he was there, and
he said, I am a diabetic and I am out of insulin. I have been
out for months, and I can't find anyone who can help me.
Like thousands of others returning as evacuees from the
hurricane, Mike had returned to a city where health care was
limited and the majority of residents are now uninsured. On
this day, he along with 600 other patients received free
medical care.
We brought in more than 400 doctors, dentists, and nurses
from across the country with a total of 891 volunteers to
provide 9,000 medical services to more than 3,000 patients by
week end. These services included dental work, eye exams, free
glasses, primary health care, OB/GYN services, diabetic care,
pediatric, and cardiology care.
To accommodate the influx of patients, we set up 20,000
square feet of tent space to serve as additional exam rooms.
This is simply a larger version of what we do every day in
New Orleans. For Mike, help was as simple as giving him one
blood glucose meter to test his blood sugar and a vial of
insulin. This is what he needed to survive, was a little bottle
of insulin and he couldn't get anyone to help him.
Our patients still, 18 months after Katrina, get in line
before daylight every day. Over 50 percent have high blood
pressure. 30 percent of those with high blood pressure come to
our door in crisis with blood pressure so high they cannot be
managed. 26 percent of our patients are diabetic. Many walk
through the door daily with blood sugar so high they cannot be
measured by the instruments that we have. Two to three patients
per week come through the door and have not had their insulin
since Katrina. They just heard about us and just showed up at
our door because no one would help them. Patients are turned
away from the free clinics and turned away from the hospitals
because they are at capacity every day.
These citizens are not what you classically think of when
you think of indigent patients. These citizens, just 18 months
ago, owned their own homes, worked full time, went to their
children's band performances and volunteered in their
community. They were just like you and your neighbors, people
you would invite over to your home for dinner.
Would you feel comfortable if your neighbors had to stand
in line all night in the cold to see a doctor? Or would you
feel comfortable if they had to be sent to a hospital in an
ambulance where they were told they had to wait in the
ambulance 4 to 5 hours before being admitted into the emergency
room because the emergency room was so overcrowded? The
question then is who is your neighbor? Who is my neighbor? Is
it just the family whose grass meets ours or should we be
concerned about those Americans we have not yet met?
This population is our modern-day Job. They have lost their
loved ones, their homes, their cars, their jobs, and their
insurance. According to the local newspaper, we now have
127,000 uninsured residents in greater New Orleans. They see
others profiting from a disaster in which they lost everything,
including their faith in a system which had promised them
health care, insurance, pensions, and most importantly,
protection.
The video said that Dr. Steven's office in New Orleans has
stated that the death rate is 48 percent higher per capita now
than it was before Katrina. The infant mortality rate is five
times higher now than before Katrina. And the level of
depression is present now in rates never before seen in the
United States. This depression and stress act to worsen and
exacerbate the individual health care issues and disease
process.
We are here to discuss what needs to be done going forward.
I would ask you to build a system where it is easier for non-
profit agencies to operate in the disaster-stricken area.
Operation Blessing can provide its own infrastructure but many
non-profits cannot. Please build a system where they can
operate.
Create a system where doctors and nurses that pass national
boards and exams are allowed to come and practice in a State
that is under a disaster notice. Last week, the State of
Louisiana Board of Nursing declared they would no longer allow
volunteer nurses from other States to come in and work. They
said they did not need them.
Again, our patients get in line at 3:00 and 4:00 in the
morning. We turn away 75 patients a day when we see 100
patients a day, and the State of Louisiana Board of Nursing
says we are not going to let any more volunteer nurses come in.
They need your oversight.
Build a system that encourages for-profit providers to
return to a region where the dollars follow the patient, where
the uninsured have choices and can seek care and private health
care facilities and those doctors and offices and hospitals are
reimbursed for that care.
Among the recommendations being considered to improve
primary and preventative care are technology initiatives to
track the person's medical history and to create community
health care clinics. These community clinics would refer
patients to specialists, manage disease care, and provide a
consistent system for tracking care.
And please remember that everything that was needed by the
New Orleans is also needed by the health care system you seek
to rebuild. Infrastructure such as housing, schools for
doctors' and nurses' children, utilities, and people with the
economic ability to pay for these services that are being
offered. All of these are necessary for a sustainable health
care system.
To close, I would like to state that Operation Blessing has
provided free medical and dental services to more than 15,000
patients. We have spent $1.5 million. But because we are able
to work with volunteers, we have delivered $11 to $12 million
worth of medical services to these patients. We could only do
this by partnering with other agencies and collaborative
efforts with our volunteers and donors.
We would like to thank all those who have made this
possible. We are grateful for the opportunity to serve the
residents of New Orleans and to serve the United States of
America. Thank you.
[The prepared statement of Dr. Koehl appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you, Mr. Koehl.
Dr. Cathi Fontenot, medical director, Medical Center of
Louisiana, New Orleans. Cathi, 5 minutes, please, if you would?
STATEMENT OF CATHI FONTENOT, M.D., MEDICAL DIRECTOR, MEDICAL
CENTER OF LOUISIANA AT NEW ORLEANS
Dr. Fontenot. Good morning. I would first like to thank
members of the subcommittee including Chairman Stupak and
Ranking Member Whitfield and others on this committee who came
down to visit with us and go through Charity Hospital a little
over a year ago and actually since that time as well.
My name is Cathi Fontenot. I am the medical director of the
Medical Center of Louisiana at New Orleans comprised of both
Charity and University Hospitals. I would like to take this
opportunity for a brief visit back to New Orleans during that
week in August 2005. We have got a 2-minute video, and I
promise I will keep to my 5 minutes.
[Video shown.]
The storm effectively destroyed both facilities, University
at Charity Hospital. That loss has been devastating to the
community. The current status of health care infrastructure in
New Orleans is tenuous and critically ill. We have been able to
temporarily reopen portions of University Hospital, restoring
approximately 140 inpatient beds including the trauma center I
might add; but sicker patients who in many cases have lost
their health care providers present to our emergency rooms with
uncontrolled disease processes due to lack of primary care and
access to medications as you have already heard.
Cancer patients who present to our hospital with no health
insurance have no choice but to travel 60 miles to a rural LSU
Hospital for their chemo or radiation and back home while weak
and miserable, and that is assuming they have transportation.
The status of behavioral health is even more dismal with
limited outpatient and inpatient services in the greater New
Orleans area. In our emergency room alone there are days when
half of our emergency department beds are occupied by
psychiatric patients because there are no inpatient beds
available for them.
Solutions to the health care crisis in New Orleans are
being developed with partners that you see here at this table
but are constrained by availability of space and health care
providers, both primary care and specialists. A critical
component of the effort to restore health care services
involves establishing and strengthening the network of
neighborhood clinics that we refer to as PATH, the Partners to
Access for Heath Care for the Uninsured where we serve as the
major hospital partner and provide hospital services as well as
specialty access. It is only this sort of collaborative effort
that can be a real opportunity to accomplish health care reform
as we go forward in the New Orleans area.
The plan for the Medical Center includes the establishment
of the community primary care clinics of our own also in
temporary facilities so that primary care can be delivered in
communities where the basic principles of prevention and
disease management are best delivered. One of the major
challenges for health care providers in the New Orleans region
is the lack of access to specialty care, and we anticipate that
at least to some degree we can maximize the use of the limited
specialty care available by using telemedicine technology,
becoming more efficient at directing patients to the right
place for the right reason at the right time.
A shared electronic record is critical to such a network of
providers, in order to share information, eliminate costly
duplication of effort. We look forward to continuing our work
with other safety net providers because such a coalition is
crucial to real health care reform and necessary for
institution of a new model of health care in the region, and we
are proud to serve as a partner in that endeavor.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Fontenot appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you. Next we have Dr. Bryan Bertucci,
coroner/family physician, St. Bernard Health Center, Chalmette,
Louisiana. Doctor?
STATEMENT OF BRYAN BERTUCCI, M.D., CORONER/FAMILY PHYSICIAN,
ST. BERNARD HEALTH CENTER
Dr. Bertucci. Good morning. God bless you and God bless
America.
Disease and death know no party, and I am happy to say we
are here for the patients' interests today; and I appreciate
the opportunity to speak.
My name is Dr. Bryan Bertucci. I am a family practice
physician and the coroner of St. Bernard Parish.
Medicine is not well in St. Bernard. One hundred percent of
our homes, offices, and buildings were destroyed, and for the
first time in history, FEMA declared a parish or country 100
percent destroyed. One hundred fifty-four St. Bernard residents
died.
St. Bernard was flooded twice by Hurricanes Rita and
Katrina, experienced an oil spill, liquid mud, mold, snakes,
flies, mosquitoes, piles of trash, mice and rats. St. Bernard
is a very difficult place to live, and despite that, our
residents returned. You have to be tough to live in St. Bernard
Parish.
Our biggest hindrance is the overwhelming lack of medical
facilities. Our 194-bed hospital was destroyed. One hundred
fifty physicians left, and now we only have six. We have 10
registered nurses.
I have some slides.
[Slide shown.]
This is of the office building where I practiced that
housed 20 primary care doctors. We lost all those doctors. That
had 13 feet of water. You can just go through the slides until
we get to the clinic.
You are asking, what can we do? Well, first, you have
already started by giving student loan deferments for the
people coming out of medical school to help pay off their
loans. That is No. 1. The biggest loss was young primary care
doctors. That was our largest loss. We need to get those people
back. Without the primary care, you are not going to get the
specialist. Without the specialist, the hospitals can't support
themselves.
Second, SBA loans. I still cannot get an SBA loan to
rebuild my office, so I can't imagine what the other doctors
are trying to do. We also need loans for people who weren't
there before, low-interest loans to help them build their
offices. You need to have increased recompensation for those
doctors, and you need housing. The three doctors that are
working in my office all live in trailers. We all lost our
homes. We have no office space available for these people to
come back.
The buildings that we lost, and I am sorry because we went
through so fast, but all of those buildings are totally
destroyed. We have no housing for our specialists.
Mr. Stupak. We can go through them quick one more time if
you would like?
Dr. Bertucci. Yes, if you would.
Mr. Stupak. Go through the slides again, please.
Dr. Bertucci. Next?
[Slide shown.]
Yes, this is our neurologist's office.
Mr. Stupak. Is that open now?
Dr. Bertucci. No. All of these were just taken 3 days ago.
Mr. Stupak. OK.
[Slide shown.]
Dr. Bertucci. This is a pediatrics office.
[Slide shown.]
This is an ear, nose, and throat office.
[Slide shown.]
That is another ear, nose, and throat office. And this is
actually rebuilt.
[Slide shown.]
This is one of our two clinics at work. This is a dialysis
unit, and obviously you see the condition of the ground
surrounding it; but we are rebuilding ourselves. We have an eye
doctor, too.
[Slide shown.]
This is our pharmacy. We actually have six pharmacies back.
[Slides shown.]
And the next picture, this is our mental health trailer and
this is the trailers that we work in.
Perhaps I think our biggest encounter and problem was
getting funding back to rebuild our facilities. Chalmette
Medical Center was a fee-for-service medical hospital; and as
such, we were penalized for being privatized. We were told that
we couldn't have any money from FEMA because we were a fee-for-
service. The Community Disaster Loan didn't qualify because we
weren't on the parish budget, so we were penalized for being
independent. The Stafford Act obviously didn't allow doctors
and nurses to get paid, and the Community Block Grant money,
$621 million went to the parish, medicine got none because we
were fee-for-service.
Perhaps our biggest problem is that Federal and State
officials do not realize that St. Bernard is not part of New
Orleans Parish. Funds that go to Orleans Parish stay in Orleans
Parish.
Medicine has metamorphosized itself from the DMAT teams
which you saw pictures of, public health, to a 22,000 square
foot trailer. We see 100 to 120 patients a day. The severity of
the illnesses that we see are equivalent to a small emergency
room or an urgent care center. We I&D abscesses, suture
lacerations, stabilize MIs and congestive heart failure, and
give IV fluids and IV antibiotics. Almost a quarter of these
patients have no insurance and are no-pay or self-pay.
A foundation is willing to give us 30 acres of land to
build a new hospital that is 8 feet higher than where Chalmette
Medical Center was located. The Franciscans has offered us
financial and professional help to try and make these dreams
become a reality.
Mental health is in crisis. Fifty to 60 percent of the
patients I see and 20 to 30 percent of the children I see are
depressed. Drug overdose is a problem in our parish, and we
have no substance abuse clinics or beds to put these people in;
and the schizophrenics or psychotics due to lack of access to
outpatient care have become a problem for our emergency rooms.
St. Bernard is lacking significant emergency room services
and has to ship patients 18 to 35 miles to an emergency room.
Our parish is surrounded by water and our limited ambulances
have to cross bridges, railroad tracks, and circumvent traffic
jams. A routine emergency room visit takes 4 to 8 hours.
The logical solution for St. Bernard is a permanent
physician office building, outpatient surgery center,
outpatient diagnostic center, and eventually a hospital.
The medical village will assure primary care and specialty
return. It will decrease the number of our residents who have
to go out to emergency rooms and free up our ambulances and
free up Orleans' emergency room beds. It will allow our elderly
to return so that we can have nursing homes and we can have
homes for assisted living. It will provide jobs as the hospital
was one of the largest employers in our parish. It also had 24
psych beds so psych beds are a possibility. If you want
electronic medical records and a medical home, we need primary
care doctors, we need specialists who will support that
concept, and we need a hospital as a safety net for the
patients who can't be controlled as an outpatient.
We need three big things. We need the bridge money, Social
Service Block Grant Money with an extension of the funds that
are due to expire on July 31. We do have some allocated to us.
We need that expanded.
We need to make more SSBG funds available to medicine for
permanent structures or infrastructure. We need Community Block
Grant Funds available to us now that we have a non-profit
institution. We are not fee for services. We are a non-profit
so that we can have permanent building structures. And we need
most importantly a rural designation for our Medicaid and
Medicaid patients to help offset the cost of treating indigent
patients for hospitals and physicians. We need some help with
the rural reimbursement.
What if your child had a problem and you knew what they
needed? As a parent, what would you do? St. Bernard, America is
your child. We need your help. We need brick and we need
mortar. We need permanent physician office buildings and we
need a hospital.
As the hospitals meet later today----
Mr. Stupak. Doctor, please summarize.
Dr. Bertucci. I am going to finish. As the hospitals meet
later today, leave an empty chair for St. Bernard. We had 240
hospital beds. Imagine the pain of our residents as they hear
the justifiable cries for help from the other hospitals and
while you call the name for St. Bernard, you hear just silence.
We need a hospital. We need your help. Thank you for listening.
[The prepared statement of Dr. Bertucci appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you. Dr. Karen DeSalvo is executive
director of Tulane University Community Health Center at
Covenant House.
STATEMENT OF KAREN DESALVO, M.D. EXECUTIVE DIRECTOR, TULANE
UNIVERSITY COMMUNITY HEALTH CENTER AT COVENANT HOUSE
Dr. DeSalvo. Good morning, Mr. Chairman and members of the
subcommittee. Thank you all for having us here today. I just
want to say it is really an honor to be on this panel with a
lot of folks that I have rolled up my sleeves and been working
with in the past 18 months now, some of whom I didn't even know
before the storm.
As you said, I am Karen DeSalvo. I am the executive
director of the Tulane University Community Health Center at
Covenant House which is a clinic formed in the aftermath of the
storm to meet the urgent needs of our city's population.
Today I am going to share with you my perspective as a
primary care physician caring for the uninsured patients in our
city, and I want to give you a snapshot of what it is like to
practice medicine in New Orleans including describing our
successes and challenges and suggest what would help improve
access to care immediately while we debate the larger policy
issues.
We have come a long way in restoring care in our city
despite the many struggles that we still have, and while much
has been made of the divisions, an often overlooked bright spot
has been the progress we have made in building a primary care
network for our most vulnerable citizens.
The Tulane Community Health Center at Covenant House is an
example of such a success. We started as a makeshift clinic. We
were just a post-Katrina first aid station. It was only a card
table and basic supplies. This was in early September 2005.
We have evolved into a prototype medical home and become a
source of care for hundreds of patients and have seen over
12,000 of them since opening our doors. Our medical home is
able to provide free care. It is basic primary care for adults.
We are a multidisciplinary team. The typical patient that we
see is middle-aged, they are uninsured, and they have multiple
chronic diseases.
To serve them we have begged, bartered, negotiated, access
to basic laboratory and diagnostic studies. We are able to use
a sophisticated electronic medical record to help us manage our
populations and be as cost effective as possible. We are also
filling a training void for health professionals with the added
benefit of exposing the next generation of clinicians to a
patient-centered model of primary care.
We are determined to keep our doors open to provide these
critical services to those that otherwise have no alternatives,
and we have received some Government support from SSBG but have
been forced to string together other funding from a wide array
of entities ranging from individual donors to corporations to
the people of Cutter.
If you could show the map, I would appreciate it.
[Slide shown.]
You have heard a lot today about something called the PATH
network and while we are proud of what we are able to do for
patients at our own medical home at Covenant House, we really
could not do this without our community partners. We are part
of a larger system of care that has emerged since the storm to
fill the void left when our traditional safety net was
essentially washed away. The projected map shows the clinical
providers in this group, many of whom are sitting here at this
table today. We call this the Partnership for Access to Health
Care Path. This pre-storm entity has actually gone from being a
simple way to connect health information to actually being a
loose network that includes government, faith-based, not-for-
profit clinical entities.
Every dot on the map represents a clinic of some sort. Some
are small, school based, some are mobile units, some are still
tents, but really many are becoming more permanent sites in
these neighborhoods.
Inclusion in the group by the way is open to any one who is
willing to share in our core values of quality and cost
effectiveness and the mission of serving the underserved.
They worked together to fill gaps in services and develop
models in the medical home, and altogether we are able to take
care of about 900 patients a day, most all of whom are
uninsured and representative of the rich diversity that is our
new New Orleans.
With continued support and additional resources, I believe
that PATH could serve as the core of a future medical home
system of care that really could transform health care in
Louisiana.
Despite our rosy progress, we do face many critical
challenges that have been described already today but I will
highlight a few. Our major limitations involve poor access to
specialty care and diagnostic services. For example, our
patients don't have access to colon cancer screening or
diabetic eye care. We don't have access to urgent diagnostic
studies for like brain imaging for example, and so we sometimes
need to rely on sending patients to the emergency room for such
tests which is a highly expensive alternative, or patients
often go without, arriving eventually at the hospital with
significant or long-term health consequences that is a much
more expensive alternative and makes them non-productive
members of our community.
As you might imagine finding clinical personnel willing to
either stay in or move to New Orleans is quite the challenge.
They have rational concerns about long-term job security and
find it difficult to maintain a high standard of practice in a
broken environment. This shortage of clinicians mean that we
are turning patients away every day.
So what can you do? The most cost-effective means to
rebuilding our health system I believe is to build a robust
primary health care system. This will unclog the overwhelmed
hospital system because it will prevent hospital admissions and
help save money through slowing the progression of chronic
disease.
The three ways that I think you can help are extend the
SSBG deadline to provide further resources for funding through
that revenue stream as well as provide further resources
through the deficit reduction act funding. As was mentioned, at
the end of July, our Federal funding from SSBG will end and
would like to request at least a 1-year extension on that
deadline.
I also believe that perhaps using the discretionary DRA
funds could be a way to support and grow more primary care
infrastructure to provide a bridge to our future health care
system.
Number 2, we need more financial support for clinicians to
help with retention and recruitment in the form of loan
repayment, malpractice support, SBA loans, as well as
uncompensated care payments directed at physicians, and
finally, through the expansion of coverage such as programs in
Medicaid.
And the third thing is I would like to ask you to assist us
as we progress, and please hold us accountable for what we are
doing. This hearing has been a catalyst for us locally. We have
had better communication and coordination than we have had in
months. It has made us all stop and clearly articulate what we
think we need to provide the immediate care for our population.
So we look forward to continuing to work with you. And I
certainly want to invite you to come visit our clinics in the
city of New Orleans.
Thank you very much.
[The prepared statement of Dr. DeSalvo appears at the
conclusion of the hearing.]
Mr. Stupak. Next we will hear from Donald Erwin, president/
CEO, St. Thomas Community Health Center. Dr. Erwin?
STATEMENT OF DONALD T. ERWIN, M.D., PRESIDENT/CEO, ST. THOMAS
COMMUNITY HEALTH CENTER
Dr. Erwin. Good morning, Mr. Chairman. I am Dr. Donald
Erwin, representing the St. Thomas Community Health Center in
New Orleans.
I would like to thank you for holding these hearings and
for the continued interest you have shown in our community. I
am pleased to be here to add to the discussion.
St. Thomas Clinic is one of the PATH clinics which was
established in 1987 by a partnership with the residents of the
country's oldest public housing development and leaders in the
medical and faith-based communities. These citizens simply
wanted accessible primary care in their community.
For 20 years, St. Thomas provided care to all patients
regardless of ability to pay. Pre-Katrina, St. Thomas primarily
served the immediate community. We learned at that time that
public/private relationships such as the ones St. Thomas Clinic
had had for years with the Ochsner Clinic Foundation are very
valuable.
Six weeks after Katrina, St. Thomas reopened and we
immediately realized we had a different population of patients.
For years the clinic had cared for patients in the nearby
community. Post Katrina, we now saw patients from all over the
city, many of whom had previously had health insurance through
their work. They had been insured all their lives but were now
uninsured because their jobs were gone. 7,000 school teachers
alone were suddenly without insurance when the school system
closed since 50 percent of the physicians who were practicing
in New Orleans before Katrina have not returned. St. Thomas
also had a substantial number of patients who had insurance but
no physician and thus turned to us.
This is worth emphasizing. Even patients with insurance had
no place to go for health care because the health care system
was and remains overwhelmed.
As we cared for an entirely different patient population
without funding to support this new demand, St. Thomas sought
partners. The clinic developed partnerships with supporters who
worked with us and with each other to maximize their support to
our clinic.
I am not sure of the patient numbers in the first chaotic
months, but over the last 15 months, over 23,000 patient visits
have occurred on our clinic's 5,200 square feet of space.
Through one partnership, St. Thomas is now the only site in the
city where uninsured women can receive mammography with
appropriate follow-up care as necessary.
As another example, a group of eight different
organizations joined together to provide our patients care for
cardiac disease at St. Thomas. Since Katrina, St. Thomas has
received support from over 30 sources. The clinic now offers
primary and preventative care as well as specialty
consultations and six different medical and surgical
specialties.
Last month we leased a building to provide mental health
care to the community. We need funds to support this
development. As one physician mentioned, we are not seeing
post-traumatic stress syndrome yet because the trauma is not
yet over. We find that the relationships we have with the other
PATH clinics benefit both of us equally.
St. Thomas raised $1.4 million in the last 18 months. We
had no choice but to try to do so since the needs of our
patients were great and they had no place else to go for care.
The country has been generous to St. Thomas. In turn, we are
good stewards and amplify the gifts we receive.
But St. Thomas cannot live on philanthropy. We cannot
survive that way. The St. Thomas Clinic has no guaranteed or
predictable funding. As the chairman mentioned, there are broad
policy discussions going on now about the future of health care
in Louisiana. But whatever model is ultimately accepted is
years away from implementation.
In the meantime, St. Thomas and PATH clinics like it will
continue to provide major care for the uninsured. We predicted
a financial deficit of $800,000 this year. We were relieved to
be eligible for $755,000 from a Social Service Block Grant.
This as a critical source but it was for only 1 year. We
estimate another $800,000 deficit for the coming year, again to
be covered with patchwork financing.
St. Thomas is emblematic of several small clinics that have
become the type of efficient and effective providers needed to
care for large numbers of uninsured patients. But these clinics
need help. If we would not be there, there would be long lines
at other clinics, more overcrowded emergency room visits, and
more expensive hospitalizations. High quality primary care is
the least expensive way to provide the best medical care in the
community.
I urge Congress to develop a process to provide gap funding
for primary care clinics like St. Thomas that have no
guaranteed recurrent funding. Whether it is through SSBG or
some other mechanism is not for me to postulate, but I do hope
that you agree that St. Thomas and other clinics like it are
essential to providing care for the uninsured; and I hope you
will continue to support our efforts to provide care for the
citizens of our community.
I ask that you find a way to provide St. Thomas and other
safety-net clinics with predictable, sustainable funding. I
appreciate the opportunity to speak to you and thank you again,
Mr. Chairman.
[The prepared statement of Dr. Erwin appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you, Dr. Erwin. Next we will hear from
Dr. Evangeline Franklin, director of Clinical Services and
Employee Health, City of New Orleans Health Department. Dr.
Franklin?
STATEMENT OF EVANGELINE R. FRANKLIN, M.D., DIRECTOR OF CLINICAL
SERVICES AND EMPLOYEE HEALTH, CITY OF NEW ORLEANS HEALTH
DEPARTMENT
Dr. Franklin. My name is Dr. Evangeline Franklin. I am
director of Clinical Services and Employee Health for the New
Orleans Health Department, also a member of the Partners for
Access to Healthcare.
To you, Mr. Chairman, and to Ranking Member Whitfield and
distinguished members and guests of the subcommittee, I would
like to thank you for the opportunity to speak to you today
about the two outdoor health clinics in New Orleans the Health
Department recently held in the city of New Orleans.
Mayor C. Ray Nagin and members of his administration have
sought creative means of addressing our citizens' critical
health needs as we work to recover from the tragedy of
Hurricane Katrina and the subsequent flooding.
Today I would like to describe to you a city, indeed a
region, which continues in health crisis despite the efforts of
all of our organizations. This crisis results from a
combination of factors. The people of New Orleans face many
challenges such as the difficulty of returning to rebuild homes
and businesses, the tendency to ignore their chronic illnesses
that these stressful distractions have caused or exacerbated,
and the complexity of the processes to claim insurance proceeds
or funds from the Louisiana Road Home Program, the State
initiative to compensate homeowners for their losses in
Hurricanes Katrina and Rita.
All of these factors are complicated by a health care
system that is itself damaged and under stress, further
limiting the access to health care that even before Katrina was
not ideal.
In the aftermath of the hurricane, the population of the
uninsured in New Orleans has expanded from traditionally
uninsured groups to include many who have experienced sudden
loss of benefits, including individuals who were laid off from
jobs because of the destruction of their place of employment or
due to loss of market or tax base. Many of these people
returned to New Orleans following the floods because of
personal or business financial commitments or because they
simply just wanted to come home.
The composition of our uninsured also includes persons who
cannot speak English and those who cannot secure health
insurance because of their migrant worker status or because
they lack the proper immigration documentation. Many of our
uninsured are part of the working poor who toil daily in their
jobs but who are not offered or who cannot afford insurance.
Hurricane Katrina and the subsequent flooding were
responsible for the loss of many aspects of health care
including hospitals, doctors, medical records, and pharmacies.
It has also meant that many people lost their medications and
let us not forget their dentures and their eyeglasses.
This when coupled with the physical and psychological
hazards of devastation have put patients previously stabilized
at risk. Imagine trying to fix your house when you cannot see.
I was assigned to coordinate two large-scale health care
events designed to provide medical, dental, and optical
services and to assist in organizing follow-up. Helping
patients regain some control of health problems would enable
our community to better manage health resources such as
emergency room use and admission to hospitals.
Both of these 7-day events were highly successful.
Thousands of patients were able to proceed from each outdoor
event with a 30-day supply of needed prescriptions as well as
eyeglasses, dentures, immunizations, pap tests, and information
about where to obtain follow-up medical care at many of our
participating clinics. But this occurred only after they
endured long lines, sometimes waiting all night in cold and
rainy weather to be treated on a first-come, first-served basis
by volunteers throughout the country as well as local
professionals. Typically capacity for each day was reached
within an hour of opening the registration. As a result, many
of those who needed care were unable to receive it and had to
be turned away to be seen on another day or at other locations.
The first of these events was held in February 2006 at the
Audubon Zoo, a location considered to be an oasis in the middle
of destruction. Audubon Zoo made a significant contribution by
allowing us access to their grounds to set up the clinic
locations, by housing the volunteers who came from all over the
United States, and by having their employees contribute their
time for this seven-day event.
The event was an immediate success in large part because of
its location and accessibility by car and by bus, but many
people also walked to the event. The zoo is located in an area
of the city which was among the first to repopulate because of
the lower level of damage that it sustained from flooding. FEMA
trailers were still being installed across the city.
Because of the magnitude of the catastrophe, very few
safety-net clinics and pharmacies were open at the time soon
after the flooding. Many weary patients reported that they were
unable to locate their doctors, did not know where to go to
have their prescriptions filled or refilled. Others offered
poignant stories about their inability to obtain needed care,
medications, and immunizations.
Of the 5,212 patients who received care at the Audubon
event, 27 were transferred to local hospitals for emergency
care. One of those was a revived cardiac arrest. This woman was
having her cholesterol tested, unable to get it tested at any
other local institution; and during her visit at the Reach 2010
at the Heart of New Orleans facility of the health fair, she
had a heart attack. She was unable to obtain primary care but
could be cared for after having a life-threatening emergency.
Fortunately, she is currently doing well.
Others were not so fortunate. One gentleman was given the
diagnosis of metastatic cancer. He had been told at one of the
local private hospitals that he had to pay for his diagnostic
tests before he could receive treatment. He did not have the
required money and was refused that treatment. Because Charity
Hospital had not yet reopened, there is no public facility in
the city that could provide the cancer care. Further
complicating his situation, this man could not speak English
and had no transportation. Despite these difficulties, we
arranged for this gentleman to receive care at another facility
out of town.
Many of the volunteers during the week remarked that they
had never seen so many people who were so very sick. All in
all, there were 1,300 volunteers who treated the 5,200 patients
during this event. Prescriptions were filled at no charge and
social services, including mental health, were made available
for interested patients. Volunteers traveled at their own
expense. The value of the services provided was $1.9 million.
The second event was held a year later in conjunction with
Operation Blessing who is represented here today. This
organization represents a clinic with medical, dental, and
pharmaceutical services in eastern New Orleans. The week-long
Health Recovery II was an outdoor clinic as well. The New
Orleans East location of Operation Blessing was accessible by
car and bus and had become an anchor by providing free care
before Health Recovery Week II.
This again was an idea location for the second event but
this time because neighboring communities have shown signs of
return and rebuilding. FEMA trailers placed in front of houses
in New Orleans East and the sale and purchase of property for
renovation herald the return of significant resources in terms
of professional and business community members. In addition,
citizens from eastern New Orleans were part of the regular
patient population of Operation Blessing. Because the medical
director is fluent in Spanish and Vietnamese, non-English
speaking residents are drawn to this facility. In addition,
this location does not interfere with the function of clinics
and services in other parts of the city where population has
stabilized.
For this event, Operation Blessing invested over $500,000
in the project for the cost of supplies, lab work, pharmacy
services, infrastructure improvement, marketing, and food and
lodging for the volunteers at their Slidell, Louisiana, command
center.
Even though more medical facilities and safety-net clinics
had been opened in the intervening year, the story was exactly
the same as before. Fewer patients were treated but only
because there were fewer volunteers who could see them. Again,
patients waited in the cold and the rain and were willing to be
seen in tents for their medical, dental, and optical care. And
again, citizens frequently stated that they could not find
their doctors and did not know where to get their medications.
The vast majority of patients seen during this health
intervention week had never been seen at Operation Blessing,
and many had been referred by other clinics to receive services
that were not available there, in particular for their denture
care and for their eye care. Of the over 3,800 patients who
were seen in the seven-day event, 21 were transferred to local
hospitals. As in the first Health Recovery Week, hundreds were
turned away after the capacity of the event filled within the
hour of its opening.
Mr. Stupak. Doctor, can you sum up, please?
Dr. Franklin. Yes, I would like to say that given the
contribution of volunteer care in the city of New Orleans, I
think attention should be made for that to continue as a
stabilizing proposition until we can recover the system.
Further recommendations will be provided by Dr. Kevin Stephens
in his testimony.
Thank you
[The prepared statement of Dr. Franklin appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you. Dr. Gary Wiltz is chairman, region
3. Explain where region 3 is to us first.
Dr. Wiltz. I will do it as I give my testimony.
Mr. Stupak. Thank you. You may start.
STATEMENT OF GARY WILTZ, M.D., CHAIRMAN, REGION 3 CONSORTIUM
Dr. Wiltz. Well, good morning, Mr. Chairman, and the
members of the committee and it is a special honor to appear
before my Congressman, Mr. Melancon.
Thank you for the opportunity to speak with you today about
the very serious and continuing health consequences of
Hurricane Katrina's aftermath. But I come before you today
wearing many hats. First and foremost I am a practicing, board-
certified internist and the CEO and medical director of the
Teche Action Clinic, a federally qualified community health
center established in 1974 located at Franklin which is a
small, rural community 100 miles southwest of New Orleans. I am
also chairman of the Governor's appointed Region 3 Health Care
Consortium which includes seven rural parishes located
immediately outside the New Orleans area. I also serve on the
Board of Directors of Louisiana Primary Care Association or the
LPC which represents State's 21 FQHC's. And finally, I am the
Board Secretary of the National Association of Community Health
Centers.
I would like to begin by telling you a little bit about my
personal history. I was born at Charity Hospital in 1953 on the
colored ward section of the then-segregated hospital. I earned
a scholarship to Tulane University and later attended Tulane
Medical School where I was fortunate enough to receive a
National Health Service Corps Scholarship. Ironically, I did
most of my residency training at the same institution where I
born, Big Charity, in New Orleans. Upon completion of my
residency, I was assigned to Teche Action Clinic in Franklin to
serve my 3-year obligation service pay-back. Twenty-five years
later, I am still practicing medicine at that same site.
In speaking of the health care realities in my home State
today, I must begin by noting the sad reality that Louisiana's
health care system was broken pre-Katrina. Louisiana had the
dubious distinction of having consistently ranked 49th or 50th
among the States in the United Health Care Foundation's annual
health status report over the past 10 years. Our health care
system has been characterized as fragmented, expensive, and
ineffective, producing far too many health outcomes.
The original concept of the Charity Hospital was to
demonstrate the compassion of the people of our State. It was
perfectly named to fulfill its founding purpose, to provide
charity. The flagship of this system located in New Orleans
fast became known affectionately by the locals as The Big Free.
Unfortunately as we all know, nothing in life is truly free.
Pre-Katrina, the residents of the seven rural parishes that
represent the Consortium depended on Charity Hospital. Katrina
essentially destroyed the health infrastructure of the entire
southeastern port of Louisiana. It also decimated the health
care workforce by displacing more than 6,000 health care
professionals, most of whom have not returned.
In the immediate aftermath of Katrina, our surrounding
parishes saw evacuees overflowing into our communities. My
family personally housed 19 family members for many months
after the disaster hit, and I am proud to say that Louisiana's
health centers responded to this tragedy as best we could but
there is still much more to be done.
Now fast forward 18 months, and where are we today? To
borrow a line from the play, The Music Man, ``Oh, we have got
troubles right here in River City''. To underscore how serious
our problems are, I give you several true-case studies. Number
1, a 38-year-old uninsured male with a diagnosis of bipolar
disorder is brought to the hospital emergency room by a
Sheriff's Deputy. Family members say that he has not seen a
psychiatrist in 18 months because of Katrina. He remains in the
hospital emergency room for 72 hours being sedated for his own
and everyone else's protection, only to be finally released to
his family when no other recourse could be found.
Second, our region's only pediatric psychiatrist has left
the area leaving hundreds of children who were under his care
in the hands of their primary care pediatrician. Our
psychiatric nurse practitioner in our system alone has a 2-
month waiting list and is seeing children now, because of the
delays are now unmedicated and have decompensated.
Finally, a 57-year-old female with chronic neck pain that
has caused numbness in both her arms and hands and decreased
motor strength has Medicaid so we were able to get an MRI and
discovered she needs a neurosurgeon. But there are no private
neurosurgeons who accept Medicaid. With Charity now closed, the
only neurosurgeons accepting Medicaid are located at the LSU
charity hospital in Shreveport, a 6-hour drive from her home,
but if only she had transportation to get there.
So now that we see what the current landscape looks like,
might I suggest some solutions? Let me so that while the scope
of the problems we face in our communities are so great that
they will require the kind of money that only the Federal or
State government can provide. The best solutions, however, are
not likely to be crafted out of Washington or Baton Route. Let
me add one more important point, that simply providing health
care insurance to the many uninsured, while that is a crucial
step to make health care affordable, would do little or nothing
to make health care available or accessible. We need a model
that works, that is proven, that is cost effective, culturally
competent, and that can serve as a medical home, a health care
home in fact. And the beauty of it is such a model already
exists in our Nation's community health centers.
Expansion of health centers would quickly address both the
needs of the underserved across our Nation and be a critical
step in transforming our health care system. The Federal
Government could immediately fund all the applications from
Louisiana that are already sitting at HRSA and greatly expand
access to care immediately. Coupled with an expansion of the
health center's program is the need to expand the National
Health Service Corps, the very program that brought me to the
community in need a quarter-century ago. We need a statewide
expansion of the Nation Health Service Corps that recognizes
the needs of rural Louisiana.
In closing, I leave you with the immortal words from Dr.
Martin Luther King., Jr., that are as true today as they were
40 years ago when he uttered them, ``Of all the forms of
inequality, injustice in health care is the most shocking and
inhumane.''
Thank you once again for this opportunity, and I will be
happy to answer any questions you might have.
[The prepared statement of Dr. Wiltz appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you and thank you to all of our
witnesses. As I said earlier in my opening, your courage and
heroism is an inspiration to all of us, but that is not going
to solve the health care problems in New Orleans and that is
why we are here and we are going to stay with you and we are
going to get this thing moved, prodded, whatever we have to do
to move this thing along.
I said in my opening that our hearing will focus on what
health care providers believe is the most urgent health care
issues that need to be addressed in the short term, and I
certainly get the impression from this panel that the dollars
have to follow the patient. Some of you said that directly in
your testimony, others have alluded to it. We certainly
understand the Social Service Block Grant money, the CDBG
money, and other issues we must come to cope with.
If we take the money out of it for a moment, just for a
moment, what else do we need in your opinion? Give me one thing
you think we should do, that Congress can push to do, that
should be done to help you out? Ms. Rowland, we will start with
you and then proceed right down the line.
Ms. Rowland. I certainly think acting on some of the
recommendations that have already been put forth to the
Department such as expanding availability of community health
centers so that the funds can be released for that, extending
the Block Grant was one issue, but I think really putting the
resources of the Public Health Service together with needs on
the ground to use every available resource that the Federal
Government has to help build community health centers, to help
build more mental health capacity, and as the last speaker just
mentioned, to bring the National Health Service Corps in to
help to establish some of the doctor needs during the time when
you are recruiting back positions.
Mr. Stupak. Mr. Koehl?
Mr. Koehl. The only thing that we would ask would be this
group push to allow our volunteer nurses to come and work.
Without them we will only see 25, 30 patients a day. These
nurses triage, they take vitals, they dress wounds, they assist
the physicians in every way possible.
Mr. Stupak. Is that more than just nurses?
Mr. Koehl. Nurses and nurse practitioners will no longer be
allowed to volunteer in the State of Louisiana by the end of
this month without the Louisiana State Board of----
Mr. Stupak. By the end of March?
Mr. Koehl. Yes, if they will not allow them to come
volunteer. And our nurse practitioners are providers just like
doctors, so that will limit the number of patients that are
being seen.
Mr. Stupak. Any other medical profession run into the same
thing, where they cannot volunteer?
Mr. Koehl. No.
Mr. Stupak. It is just the nurse?
Mr. Koehl. Different board, different group of people
making the decision.
Mr. Stupak. OK. Dr. Fontenot?
Dr. Fontenot. Unfortunately I think it ultimately comes
down to money, but certainly helping in the recruitment efforts
by using U.S. Public Health Service Corps. The regional
designation for underserved community probably applies to more
than the four-parish area that is currently designated as I
understand it and redeveloping infrastructure, namely
electronic means of sharing data among the partners who are now
responsible for providing care.
Mr. Stupak. OK. Dr. Bertucci?
Dr. Bertucci. Well, and again, it does come to money. It
does come to money. We need to get our primary care physicians
back and our specialists back so that we can do medical homes.
Without those particular individuals, it is impossible. It does
come down to the fact that we do need dollars. In order to have
a medical home, you have to have primary care physicians, you
have to have specialists, and you have to have some buildings
for these people to work in.
Mr. Stupak. But didn't you say you have to start with the
primary care in order to get the specialists to come in?
Dr. Bertucci. I agree with that. We need buildings, though,
to put those people in. Right there in our particular parish we
are kind of unique in the fact that we do not have buildings to
stick people in, and even if the specialists wanted to come
right now, we wouldn't have a place to put them.
Mr. Stupak. Right.
Dr. Bertucci. So we need some of the SBA loans so that they
can build.
Mr. Stupak. Sure.
Dr. Bertucci. We need some low-interest loans for people
who don't qualify for SBA so they can build. So I think those
are the biggest things, and I think the bridge money so we can
sustain our clinics, especially the rural reimbursement, would
help us tremendously in both maintaining our clinic and
building a hospital.
Mr. Stupak. Dr. DeSalvo?
Dr. DeSalvo. You could come rip up the frayed carpet in our
stairwells so it wouldn't be so hard for people to get up and
down the stairs and help us slap some paint on the walls, but
aside from that--which we will pay for the paint, by the way--I
am a National Health Service Corps person as well. I was
assigned to Charity Hospital and was retained, apparently, for
all these years. And so I think it is an excellent program if
some of the bureaucracy is weeded out so that if we know there
are people who are using that for loan repayment and they will
be assigned to New Orleans.
Mr. Stupak. Let me ask you this. Let me just follow this up
a little bit. And I know I did not want to talk about dollars,
while I got you here I only got a few minutes left, what about
DSH dollars going to clinics and doctors?
Dr. DeSalvo. I am sorry?
Mr. Stupak. What about DSH going to clinics and doctors?
Dr. DeSalvo. I am not a DSH expert, but from what I
understand----
Mr. Stupak. But you are a practical expert so I want
practical answers.
Dr. DeSalvo [continuing.] experience is that the way we DSH
in Louisiana it doesn't--we can't apply for that through
matching dollars at our clinic----
Mr. Stupak. We have to get a State or Federal waiver,
right?
Dr. DeSalvo. I would have to refer that to Diane.
Mr. Stupak. Ms. Rowland, we also get a State waiver, I
believe, if I am right.
Ms. Rowland. The DSH funds actually flow through hospital
and inpatient hospital care. So you would need a waiver under
Federal law to use them for alternative sources.
Mr. Stupak. OK. So you need State waiver and Federal
waiver?
Ms. Rowland. You need the State to request a Federal
waiver. It is the Federal Government that would--
Mr. Stupak. But the State would still have to change its
law, though, to allow it to go other than hospitals to clinics.
So you need a change in State law, then they have to apply for
the Federal 1115 waiver, correct?
Ms. Rowland. Right, and there was a previous waiver that
was pending at the time Katrina hit that you reactivated and as
a small point, I mean, I would say yes, we need money. We just
need money.
Mr. Stupak. Right.
Ms. Rowland. But the SSBG's for example is essentially a
no-cost extension is what we want.
Mr. Stupak. Dr. Erwin?
Dr. Erwin. I would like to see whatever way we could do it
that we develop an incentive to focus on partnerships of these
primary care clinics with specialty providers and hospitals.
Where we have been most successful at St. Thomas has been the
ability through collaborations and sometimes paying for the
specialists, to be able to provide timely outpatient specialty
services. Everybody agrees that the highest quality, most cost-
efficient care is when the physician who knows the most about
that specific illness manages the patient. And when we get used
to thinking of specialty care as the tertiary hospital
specialty care, and I think there are so many instances where
the cardiologist helps patients out of the hospital by managing
their heart failure and the nephrologist helps prevent patients
going onto dialysis by appropriately intervening. So I would
really like to encourage you to help provide whatever incentive
is possible to link the primary care clinics with specialty
services and hospitalization.
Mr. Stupak. OK. Dr. Franklin?
Dr. Franklin. From our experience at Operation Blessing and
from our experience in the health clinics in New Orleans, I
would like to focus on cultural competence in medical
translations being part of the practical problems that we
actually have to approach. We have numerous individuals in the
city who do not speak English. We have had a population of
Hispanic and Vietnamese before the storm, but the population,
especially of non-English speaking Hispanics, has increased.
Since my colleagues have done such a good job of talking about
the medical issues, DSH dollars, that sort of thing, I would
like to focus on eyeglasses, optical care. As I said, imagine
trying to find a job or fix your house when you can't see.
Mr. Stupak. Dr. Wiltz?
Dr. Wiltz. Yes. Mr. Chairman, I think you actually hit on
it early on, the chicken or the egg; and I think the problem is
we need both concomitantly workforce development as well as
infrastructure. Before I left, I saw an e-mail that I don't
know where it generated from but there was something being
bantered about that there was a $15 million grant from DHH that
was described as a New Orleans Health Service Corps that was
being offered, and maybe one of the other panelists will allude
on that. But I think something in that regard that is expanded
for all of Louisiana, particularly in the rural communities
outside of New Orleans that were sort of depended upon Charity
Hospital for specialty and subspecialty care and of course the
development of FQHC's.
Mr. Stupak. I think that $15 million was something Mr.
Melancon has been working on for a while. Maybe he can expand
on that a little bit more.
Let me ask this question here. Dr. Fontenot, if I live in
New Orleans, I have lost my house, my job, I have no health
insurance, and let us say I have some type of cancer and I used
to go to a clinic at Big Charity for my chemotherapy, what do I
do now?
Dr. Fontenot. You probably still come to Charity, either
through the emergency room or through its primary care clinic
and get referred to a sister public institution about 60 miles
away where there are oncology services available.
Mr. Stupak. As Dr. Wiltz said, transportation isn't the
best in New Orleans right now. So I am unemployed, don't have
any money, I don't have a house. Well, why can't I go to one of
the private hospitals there?
Dr. Fontenot. Unless there is an emergency pending and you
need emergency care through their emergency department, I
believe they would have difficulty in referring you to a
private oncologist in town because at that point, you would
need diagnostic services and you would need chemotherapy which
is quite expensive and likely would be----
Mr. Stupak. Are there any clinics there doing chemotherapy
or anything like that?
Dr. Fontenot. Not for uninsured patients currently, no,
sir.
Mr. Stupak. If I went to emergency room at a private
hospital, would they accept me because it is chemotherapy? Does
that qualify as an emergency?
Dr. Fontenot. No, sir.
Mr. Stupak. Because it is just a continuation of treatment
of my illness, right?
Dr. Fontenot. Maintenance of, yes, treatment of your non-
emergent illness.
Mr. Stupak. My time has expired and I yield to the ranking
member for 10 minutes. Mr. Whitfield?
Mr. Whitfield. Thank you, Mr. Stupak. All of us were quite
moved I think by the statistics that you all presented in your
testimony. 48 percent more people dying each month and 90
percent of employees losing jobs at Charity University Hospital
and so forth. And it is so overwhelming what you face it is
really difficult to decide where to begin.
But I would like to ask the panel, is there one entity
within the region that all of you work with to make
presentations to the Federal Government and the State
government on the needs of the health care providers? Is there
one entity that is speaking for all of you or do you do it
separately or how is that handled?
Dr. DeSalvo. The way we have informally developed that kind
of communication is through the PATH network, the Partnership
for Access to Healthcare, so that even though it is a
federation and we don't officially lobby, we do have an
administrative entity, the Louisiana Public Health Institute,
that can bring us, convene us, coordinate us, send out
information and does things like make these maps so that we can
visually see where we need services and then look at grids of
gaps.
Mr. Whitfield. Right.
Dr. DeSalvo. They also then help communicate with the State
government for us about what future resources might be.
Mr. Whitfield. OK. So PATH is sort of the lead agency for
all the health care providers in the area?
Dr. DeSalvo. Not an agency, it is a collaboration.
Mr. Whitfield. OK. Collaboration.
Dr. Fontenot. If I might, we actually communicate and have
very good communication with Dr. Cerise with the Department of
Health and Hospitals who is the Secretary of DHH. And so he is
kept in the loop as far as especially the regional needs and
how we work together.
Mr. Whitfield. Dr. Bertucci.
Dr. Bertucci. We also participate in the Recovery Council
which has representatives from Plaquemines, Cameron, St.
Bernard, Orleans, and St. Tammany Parishes and also East Baton
Rouge. So we also give information to them and serve mainly as
an information center so that we can give that out to people of
the needs, medically, psychiatrically, et cetera, of the
different parishes. We serve more as an informational type
situation.
Dr. Wiltz. We also have the Regional 3 Consortium.
Actually, the Governor had a Health Care Commission that was
convened pre-Katrina and we were meeting on an ongoing basis to
address a lot of health care needs. Post Katrina, we continue
to meet those seven rural parishes that I represent, and there
are some other regions that are also meeting and we do present
to Dr. Cerise on an ongoing basis.
Mr. Whitfield. All right. Now, prior to Katrina, how many
hospitals were there in the New Orleans region? Does anyone
know?
Dr. Fontenot. I believe that there were about 12.
Mr. Whitfield. Twelve?
Dr. Fontenot. Don't hold me to that number specifically,
but there were about 4,400 hospital beds.
Mr. Whitfield. OK. And how many hospitals are operating
today?
Dr. Fontenot. In Orleans Parish, there are four including a
children's hospital that does not treat adults, three others
that are operating in Orleans Parish.
Mr. Whitfield. But in Bernard Parish there are zero, is
that correct?
Dr. Fontenot. Bernard has none.
Dr. Bertucci. St. Bernard had 240 hospital beds but the
population was 67,000. Right now we have zero beds and a
population of 25,000 that once the elderly and the Road Home
Funds come we assume more people will come; and in 2 years we
anticipate about 35,000 back and are working diligently to try
to get a 40-bed hospital.
Mr. Whitfield. And Dr. Wiltz, out in Franklin, you have a
hospital in operation out there now?
Dr. Wiltz. Yes. As a matter of fact, we have a new hospital
that is being constructed. That will be open in July, but that
was in the works pre-Katrina.
Mr. Whitfield. Now, in the testimony it is quite obvious
one of the major problems that you have is primary care
physicians, and as someone that is a little bit biased toward
these community health centers, I mean, I really see community
health centers as being able to provide a major role in health
care delivery around the country myself. I may be wrong, but
that is the way I feel.
Mr. Whitfield. Dr. Bertucci?
Dr. Bertucci. Well, I am a private physician and I have to
say this. I thank and I admire the public health system, don't
get me wrong. But don't discredit private fee-for-service
doctors.
We get paid and compensated much less and provide
tremendous services very, very efficiently. We are very cost
effective, very productive because we have to be. We don't get
subsidized, we don't get help. And we are trying to attract
back the private primary care and the private specialists
because I think these people need to be there, too.
We need the public health network as an umbrella, it is a
safety net, and also for service for the indigent; but we as
primary care doctors probably saw--I saw people for free all
the time. So don't discredit the fee-for-service.
Mr. Whitfield. Well, I appreciate your comments on that. I
think many of us outside of these disaster situations have
looked at the community health centers being expanded to help
address the uninsured for lack of a better--or people who
simply don't have access--people who go into the emergency
rooms--keep them out of the emergency rooms. And I agree with
you, though, that we don't need to ignore fee-for-service
primary care physician.
Dr. Bertucci. At our clinic and in my clinic before the
hurricane, no patient was ever turned away for money. Now, if
they were rude, that is a whole different story; but for money,
it is a different thing.
Mr. Whitfield. Right.
Dr. Franklin. Mr. Whitfield, I would like to say that
approximately three-quarters of the private physicians that
were in Orleans Parish are no longer there. The Health
Department continues to get calls from private physicians who
want to come back to the city who are looking for employment,
looking for an opportunity to re-establish their practices,
knowing that we have brick-and-mortar opportunities for them to
work.
Mr. Whitfield. Right. Three-quarters, these are fee-for-
service that are no longer there.
Dr. Franklin. Yes, that is correct. That is the estimate,
yes, sir.
Mr. Whitfield. Now, one of the things I remember from our
hearing in January, my memory may not be accurate so you all
can correct me but what raised this issue in my mind, Mr.
Bertucci, you were talking about the fee-for-service providers
were penalized by FEMA because you were a fee-for-service. You
were not eligible for funding, is that correct?
Dr. Bertucci. Actually, it is if the hospital was fee-for-
service.
Mr. Whitfield. OK.
Dr. Bertucci. And therefore every time we applied for any
type of financial assistance, they said that you didn't qualify
because everything is based on pre-Katrina which is fee-for-
service. And I will just leave it at that.
Each time we ran into those dead ends, we tried to--never
in the history of the United States they said has a fee-for-
service hospital not come back. And I said, well, they are not
coming back right now. What do we do?
There is no answer to that. So it is not private
physicians, this is a hospital.
Mr. Whitfield. Yes. I am going to ask you a question and I
mean I know the focus of this hearing is what can we do to
help, and all of you answered the chairman's question
specifically and you listed about 12 or 13 things that could be
done immediately. But I remember in that January hearing some
of the what I will say fee-for-service hospitals, private
hospitals, were very close to going back into operation because
they said all of them had insurance and from the insurance
proceeds they could build back and get back into business. The
State-operated hospitals were self-insured and with the size of
the catastrophe that hit, there were not enough State funds to
get them back in operation. So at Chalmette, if that was a
private hospital, what about the insurance proceeds?
Dr. Bertucci. Chalmette was in a dilemma where it had just
expanded our hospital by 17 ICU beds and 40 private beds, had
bought Methodist Hospital and Lakeland Hospital. So they also
lost those other facilities at the same time. I don't know
their insurance situation, although I saw an article in the
paper so I don't want to quote things that are not true. But
they did list the monies that they did receive, but their
intentions appear to be that they are not coming back to this
area. None that I know of at this point. So we recruited a non-
profit group, the Franciscans, to help us to secure funds to
make our dreams come true.
Mr. Whitfield. Yes, well, Mr. Chairman, as we said, this is
an overwhelming problem that we face, and I recognize the
importance of fee-for-service and do everything we can to
encourage private, paid physicians to come back. But I do hope
that our committee, full committee as well as subcommittees,
can work to try to provide expedited facilities and funding for
community health centers to provide that instant primary care
help that is needed in that area.
I will yield back the balance of my time.
Mr. Stupak. There might be some good questions there for
the third panel and ranking member's thoughts. Mr. Melancon,
from Louisiana for 10 minutes, please.
Mr. Melancon. I want to thank you all for taking the time
to come here. I think the more I listen, the more questions I
start having in my mind. I am not an authority on health care,
but I am starting to see pieces starting to fall in and coming
to understand what is going on.
I guess what one of the things that we want to see happen,
and the chairman and I and others have talked about it, we
don't want this to be you come here and testify and you go home
and we will kind of try a couple things and we will see you
later. What our discussions have been are to bring the facts
out as much as we can, try and make incremental steps here at
the beginning with recommendations from you what the Feds can
do, what maybe we can do to prod the Department of Health and
Hospitals or whomever to move things. But in roughly maybe 45
days or whatever the chairman decides to come back and revisit
that, whether it is here in Washington or back in New Orleans
and see what we have been able to accomplish, see what you have
been able to accomplish, see what new problems are out there.
And I guess the question to anyone in particular, do you think
this would help us to start that track towards getting health
care in the southeast region of this State back going in the
right direction, and if so, do you have any specific things,
suggestions that we ought to be making sure that gets done? Ms.
DeSalvo?
Dr. DeSalvo. Mr. Melancon, I mentioned this in my testimony
that I do think it would be helpful. I think the oversight has
caused some coordination in the community, being a sort of
neutral party, helps to step in. We have been meeting ourselves
to death for 18 months, so let us just remember that when we
are doing it. And I would also say that the funding relief
issue is really urgent, and I am not sure we can wait 45 days.
We spend so much time begging for dollars from foundations just
to keep our doors open, so while we are planning things, let us
make sure we provide some immediate funding relief in some way
so that we can focus on the other issues.
Mr. Melancon. Doctor?
Dr. Erwin. Yes, sir. I would certainly second that and I
would certainly hope that you do come to New Orleans and the
other parishes again mainly because speaking just for myself, I
am not involved a lot in policy. I am sort of in the forest and
sort of laboring every day and it is easy to kind of lose
perspective. You are just thinking about yourself and how to
get through the day and the patients you are seeing and how can
I get this particular person any assistance, and it is so
beneficial when people come to town who have knowledge, who
have an overview, and who have the ability to change direction
and to influence decision makers in Washington and in the State
and everywhere else. I would certainly hope that you do come
back and keep the focus that you are showing today and have
shown.
Mr. Melancon. Dr. Bertucci?
Dr. Bertucci. Yes, I think it is important that we become
your information source so that we can tell you pluses and the
minuses of the things that we have been able to accomplish. I
think that is extremely important. I think we always say be
careful what you ask for because you might get it. And the
problem is that right now, we are asking for specific things;
but in 6 months, I can tell you the way things change, the
problems will be different. So I do think it is important that
we have the opportunity to verbalize the situation to you so
you can have good information, updated information to make
decisions on.
Mr. Melancon. Dr. Wiltz?
Dr. Wiltz. I think it is critical you keep the spotlight on
the issue. I think it is critical that outcomes be measured and
progress be measured. I don't think it is enough to throw money
at any situation. I think you have to have accountability, and
it is going to be interesting. This coming week we are
expecting to hear from HRSA if all those applications are
pending for new access points as well as expanded medical
capacities that have been backlogged because you all just
passed a Continued Resolution that opened that funding up. If
that comes to pass in the next 6 months, those applications we
have to be a mandator to get those facilities up and running in
the next 6 months. So it will be interesting to see if those
monies come. You know, we can give you a progress report on how
that went.
Mr. Melancon. Dr. DeSalvo, let me suggest being from south
Louisiana, hearing politicians come down there and talk and
take pictures and come back here and forget what they saw and
didn't follow-up in many instances, I have expressed to the
leadership in this House that we are tired of hearings. We want
things to start happening.
So what I think you see here in this committee, because of
the chairman of the full committee and the chairman of the
subcommittee, Mr. Stupak, is an effort to do exactly what you
are saying, is make the meetings that you have more meaningful
and that something comes out of them. And the chairman has
assured me that he stands by that. We have got a great staff
here that understands the issues and I think will help us.
I want to encourage not only you but any panel members that
come to please stay in communication with us or the staff
because if you are anything like me, you are going to walk out
the door and say darn it, I forgot to talk about such and such.
So those ideas, those thoughts, don't let them fly past.
Make sure that we get them because we want to do whatever we
can possible. We know that money is a necessary evil, and that
is tough but we have got to address that as time goes. But
those things that will move us incrementally toward
resurrecting health care like it should be in southeast
Louisiana and for that matter a ripple effect that is starting
to go out into the country areas, we need to catch it now
before it gets to be too far gone.
Mr. Chairman, I yield back my time.
Mr. Stupak. If I may follow-up here on one point. You
mentioned these HRSA applications pending before HRSA. How many
are there and how long have they been pending?
Dr. Wiltz. We submitted them last year. There was a
statewide strategic plan that involved most of the community
health centers with anticipating spread and expansion.
Mr. Stupak. When last year?
Dr. Wiltz. I can get that information to you. I don't have
the exact number.
Mr. Stupak. OK. So it has been pending for a while?
Dr. Wiltz. Yes.
Mr. Stupak. Have they given you any indication when you can
expect a decision?
Dr. Wiltz. We were thinking we would hear something this
week. There was no funding available until you all passed that
continuing resolution. So we are expecting to hear something
hopefully this week or next week.
Mr. Stupak. OK. Why would they not move your application,
approving it pending funding? Why would you use funding as an
excuse not to do your work until----
Dr. Wiltz. Some of them were approved without funding
because you all didn't have a budget until the CR was passed is
my understanding.
Mr. Stupak. Right, but I would still think that your work
would go on, and when the funding came in you could move it. I
mean, you are sort of in a dire situation down there in New
Orleans. I mean, when we were doing the CR, there was never a
question there. The question was just how much money was going
to be there.
Dr. Wiltz. Yes, there is also some State legislation
pending now that if that goes through, we may have the
opportunity to do an even greater expansion project.
Mr. Stupak. So if HRSA approves your applications, then the
State may help you expand these qualified clinics?
Dr. Wiltz. Yes.
Ms. Rowland. Mr. Chairman?
Mr. Stupak. Yes.
Ms. Rowland. There is also monies in the Deficit Reduction
Act that allowed for development of community centers and
access to care that have not been expended yet. So there is
additional discretionary funds----
Mr. Stupak. Well, that was the 2005 Deficit Reduction Act I
think was signed into law in January 2006 if I remember
correctly.
Ms. Rowland. And the Secretary set aside those funds and
has not yet allocated most of them, so that would be an issue
you could raise in your third panel.
Mr. Stupak. Allocated because there is no request or
allocated because they just haven't gotten around to it?
Ms. Rowland. As I understand it, it was set aside. There
have been obviously requests for various support for community
health centers but have not yet designated how they are going
to allocate those funds out from the Department.
Mr. Stupak. But couldn't the current health centers that we
see before us here today access that money then, the Deficit
Reduction Act of 2005 which was approved in January 2006?
Ms. Rowland. One would assume they could under the terms of
the Deficit Reduction Act.
Mr. Stupak. I mean, that is 12, 14 months from here and we
got money sitting here, it appears to be.
Ms. Rowland. Well, I certainly think one of the things this
committee can help do is to look at where there have been snags
in resources that were intended to be utilized quickly that
have not been yet utilized, changes that could be made to flow
the funds. While it is not about money, it actually is about
the money to develop the resources.
Dr. Wiltz. I am just told that there are 287 new access
point applications pending nationwide.
Mr. Stupak. Well, they don't have to wait until the 287th
one approved. If they did the first 10, you could move those
out, roll them out, get them moving, right?
Dr. Wiltz. I agree, and as our middle name indicates in our
clinic, it is called Teche Action Clinic, and we are ready to
roll. If we had the money, we could expand within 6 months.
Ms. Rowland. One of the things we learned from the Katrina
experience is that we don't have very effective emergency
crisis management policies in any of our programs, whether it
is Medicaid to just quickly be able to extend coverage to
people who lose their homes and their insurance or to move the
community health center applications through the bureaucratic
hurdles. And so I think one thing to really look at is how can
we simplify or set up streamlined procedures that in a case
like this can relieve the DSH funds and move them quickly from
being hospital-based to community-based or to cover people or
to set up ways to get these community health center funds----
Mr. Stupak. Sure but an emergency declaration is supposed
to move that red tape quickly so you can respond quickly to the
needs of the people who are devastated, and there has been no
greater devastation of any natural disaster in this country
than this one. So I would think that once you have a disaster
declaration, that the critical needs such as health care
certainly would be moved and go through this red tape a little
quicker.
Ms. Rowland. Right, and just as Mr. Green noted, there is
no way that if it happened to Houston this year the procedures
would be any better or any quicker.
Mr. Stupak. Yes. Go ahead and then I got to get back
because they want us to be out of here by 3 o'clock, and at the
rate I am going we will never get to 3 o'clock. We will still
be on this panel and we have got two more to go. Go ahead, Dr.
Bertucci.
Dr. Bertucci. Just one example of finding problems is that
when the Social Service Block Grant came out, there was $110
million. $30 million of that went to medicine, and our numbers
got cut from $10 to $7.5 to $5 to $3.2 million and this is
medicine. Now, I mean we are talking--we need access to funds
for running our facilities but also we need some to build
facilities. And we are not a public health clinic, so we need
help, too, in order to build ourselves so that we can handle
the volume that we need to handle in our parish.
Mr. Stupak. Next we will go to Mr. Burgess of Texas for
questions. Ten minutes, Mr. Burgess.
Mr. Burgess. Thank you, Mr. Chairman. Dr. Bertucci, let me
speak with you for just a minute and then we will go to some of
these other things that have come up, particularly the snags in
the facilitation. Now, your hospital is Port Chalmette
hospital, is that right?
Dr. Bertucci. The hospital is Chalmette Medical Center.
Mr. Burgess. Chalmette Medical Center? And I visited that
in October 2005. Of all of the things that I saw when I was
down there that October, that hospital was probably the one
about which I will have nightmares the rest of my life because
it looked exactly like my community hospital in Texas, and I
could well imagine what would happen to my community in Texas
if suddenly three feet of mud, snakes, rodents, all the things
that you talked about, the oil spill. I mean, you didn't need
to just see the devastation, you could smell it and taste it in
the air still 5 or 6 weeks later. And my understanding is that
hospital no longer exists?
Dr. Bertucci. Six feet of water came up in 45 minutes. I
was actually there with 54 patients. And 6 feet of water came
up in 45 minutes and 1 foot an hour to 13 feet. So this
hospital got destroyed that day. 200 evacuees came over the
railings and were housed in the center of the hospital in the
hallways and all had to be evacuated by boat. The hospital was
irreparable, and it is a total destruction, yes.
Mr. Burgess. Well, let me ask you a question because when I
was there obviously you couldn't even get into the area unless
you signed a form for FEMA that you wouldn't hold them
responsible for what happened to you. Are people repopulating
the area now? I noticed they were when we were there, even with
those restrictions.
Dr. Bertucci. The most amazing thing is we have increased
to 25,600. There are 11,000 houses that are being built. We had
28,000 before, but 11,000 according to the newspaper, the last
article I saw, are being built. We had 1,400 businesses, now we
have 372 and people go, that is not very good. I said, when you
started at zero, that is fantastic. We actually now have
grocery stores, we have coffee shops, we have restaurants. We
have no retail stores to buy clothes still, but people are
coming back. The people of St. Bernard were the sheetrock
hangers, the painters, the roofers. If they get their Road Home
money, they will do this themselves; but they have got to get
that money, and right now the Road Home is holding us up big
time.
Mr. Burgess. Let me ask you a question because this is a
little different from the Ninth Ward question. This area was
hit by the surge or the storm surge, is that correct? Not the
levee breaks?
Dr. Bertucci. Actually, the water that I saw, and I saw
water coming that looked like it came from the industrial canal
area, and then we had the break over by Lake Borgne. So there
were two areas that flooded. The water that came in did not
come as a wave. I saw just the parking lot fill up and then
like I said, it gradually rose. I mean, 45 minutes is pretty
fast.
Mr. Burgess. Yes.
Dr. Bertucci. But it went up to 6 feet so it wasn't like a
wave that came and took the hospital down.
Mr. Burgess. Do you have a place to rebuild? If you talk
about bricks and mortar, do you have a place to build that is
higher in elevation or will you have to raise that site up?
Dr. Bertucci. Well, in order to coax the hospital back, we
actually got 30 acres of land donated that is right on St.
Bernard Highway. It is 8 feet higher than the other one. The
hospital will be built up. The St. Bernard Highway--we wanted
access after a storm to our hospital facility because you need
it. St. Bernard Highway in 2 or 3 days and you could drive back
and forth all along St. Bernard Highway. So the water receded
very quickly. St. Bernard Highway had 5 feet of water. If you
build up 8 feet and it is already 8 feet higher than where
Chalmette Medical Center is, the hospital should be able to
survive any type of flooding situation if they do the levee
systems the way they say.
Mr. Burgess. Well, obviously, the fundamental safety
question is one that I think we take very seriously. How
helpful has the Small Business Administration been to you when
you are on this effort to try to rebuild?
Dr. Bertucci. We have a civil group there that does help
quite a bit, and they are working diligently with the
Franciscans. I am a doctor, and I am trying to do my medicine
along with recruiting the funds. So I can't say that Small
Business and I have been in contact that often.
Mr. Burgess. OK. Ms. Rowland, let us talk for just a
minute. You referenced right in reference to the chairman's
follow-up questions about the snags and facilitation of getting
the funds. Now, when we received a number of displaced persons
in the Dallas-Ft. Worth area, Secretary Leavitt came and said
he was declaring a public health emergency because of the
persons who were displaced by the hurricane and that funds
would be made available. However, in Texas I know the mayors of
Dallas and Ft. Worth have had some concerns because they have
difficulty getting the money that has come to the State, they
have had difficulty getting money from the State then to filter
back to the municipal level. Has that been an issue where you
are as well?
Ms. Rowland. Well, I think that when we did some evaluation
of the waivers that were granted to help the Medicaid patients
to be covered and to provide some uncompensated care funds, the
funding for that was actually delayed until the Deficit
Reduction Act could be enacted to provide the funding.
Mr. Burgess. Wait a minute. Let us back up for a minute
because we passed a supplemental appropriation bill of I think
it was $100 billion during the fall of 2005 after Katrina hit.
It was almost like we were force-feeding Louisiana dollars, so
I guess I am a little bit--I don't understand why the Deficit
Reduction Act is coming into it even because those were monies
that were appropriated several weeks before we did the Deficit
Reduction Act.
Ms. Rowland. But it was actually through the Deficit
Reduction Act that the funding for those Medicaid waivers was
actually put in place and where the uncompensated care funds
were. So it was that that helped fund the services that were
received in Texas. And a lot of it is just there were
administrative steps that had to be gone through so that
individuals showing up at a hospital could be enrolled in the
Medicaid program. They had to refer back to Texas, and then a
lot of the people who came to your facilities were uninsured
people who were not on Medicaid, and that required the
uncompensated care funds to flow.
Mr. Burgess. Yes, separate out the Texas part for now. I am
talking strictly of what was happening in Louisiana. Out of
$100 billion that we passed in the fall of 2005, no dollars
were available for patient care until we passed the Deficit
Reduction Act in January 2006?
Ms. Rowland. Well, certainly the Medicaid funds for those
who were covered by Medicaid were available and then the
Supplemental and the Deficit Reduction Act provided the
additional financing to cover the State's share of those funds.
So there were Federal funds flowing but additional funds came
through the Deficit Reduction Act.
Mr. Burgess. Do you have any ideas as to the dollar figure
of Federal funds that have come to Louisiana? Does anyone on
the panel have a concept?
Mr. Melancon. If the gentleman yields?
Mr. Burgess. No, in fact, let me get you--you can share
that with me later. I wanted to ask Dr. Wiltz before I run out
of time about the health centers that you have that are in the
pipeline. That 287 was a figure for the entire country?
Dr. Wiltz. Right.
Mr. Burgess. You have at least 10 that are on line for your
area, region 3?
Dr. Wiltz. In region 3 we have four that are pending that
right now.
Mr. Burgess. That are pending? The applications are
pending?
Dr. Wiltz. They actually received the initials for in the
90's on the initial applications.
Mr. Burgess. And how long does it take then for HRSA to
respond with funding if you received that high score?
Dr. Wiltz. We are hoping as I said at the hearing, the next
few weeks. Now, once we get the funds, we have a mandated time
to get up and running.
Mr. Burgess. Were those applications in process before
Katrina hit?
Dr. Wiltz. Yes.
Mr. Burgess. They were? What is the timeline from when the
need was recognized and those applications were initiated to
where we are today where we are perhaps on the brink of getting
funding?
Dr. Wiltz. Maybe a year.
Mr. Burgess. Well, Katrina was 18 months ago.
Dr. Wiltz. As I said earlier, we had a Health Care
Commission that they had a statewide strategic plan pre-
Katrina. So we knew there was a shortage of community health
centers in the State already and it put in the pipeline for
this expansion pre-Katrina. And then when Katrina hit, all that
got put on hold so more recently----
Mr. Burgess. It got put on hold?
Dr. Wiltz. We had to resubmit it last year.
Mr. Burgess. That was HRSA's requirement that you resubmit
those clinics that you already knew you needed before you had a
health care disaster of this proportion.
Dr. Wiltz. I am trying to remember the timeline again, but
we get the initial score and then we didn't get funding, I know
that.
Mr. Burgess. I am not being critical. It goes back to the
issue of the snags and the facilitation. Again, $100 billion
that we sent from here to you and Mississippi and to some
extent Alabama, and where is the help for the people? That is
what is frustrating me so much. Has it been more difficult to
get those applications processed since Katrina with HRSA?
Dr. Wiltz. I wouldn't say more difficult.
Mr. Burgess. It was 18 months.
Dr. Wiltz. We transmitted them. I mean, as far as them
getting them? No, I think they have gotten them.
Mr. Burgess. It is 18 months and your mortality rate is
twice what it was with half the people, we saw on the video, so
I mean that to me would qualify for a sense of urgency.
Dr. Wiltz. Yes.
Mr. Burgess. If we were ever to have a Federal agency
recognize a sense of urgency, it seems that 18 months seems
unconscionably long to me, particularly if those applications
had already been in process before. Can you identify where it
is that this snag is occurring, where this hold-up is
occurring? Is it just with HRSA, is it something that is
happening at the local level?
Dr. Wiltz. No, I don't think it is at the local level. I
think we all recognize that model is one that can work, and we
have to get letters of approval and support from all the local
folks. So we have gotten those. I don't know why. I could not
answer that, where the snafu is.
Mr. Burgess. OK. Mr. Chairman, I hope we are able to devote
some time to winnowing that question down.
Mr. Stupak. Hopefully the third panel. Next, Ms. DeGette
from Colorado for 10 minutes.
Ms. DeGette. Thank you very much, Mr. Chairman. If we can
have the map of operating clinics and hospitals put up on the
screen?
[Slide shown.]
Ms. DeGette. This is my question. We hear everybody--and by
the way, everybody here is so dedicated. Some of you I have
been working with for a long time, ever since this terrible
tragedy; and I am always struck by the commitment of all the
health care professionals, in particular the front-line
providers, the doctors, the nurses, everybody that is out
there. It is extraordinary to see.
But my question is this. In the 18 months since Hurricane
Katrina, what we have seen is a number of clinics springing up,
and we have heard the success stories of some of them today.
Each one seems to be pursuing different sources of funding with
varying degrees of comparative success and working together at
some level. Maybe I will start with Dr. Franklin with this
question. Are these clinics springing up primarily because a
need is seen by some group and then the group pursues funding
or is there some coordination of these clinics and if not or if
it is minimal, could we have better coordination so that the
clinics that we are getting are really being used to respond to
patient needs?
Dr. Franklin. Ever since I returned from Dallas as an
evacuee, we have been working together on a regular basis,
sometimes twice a week as a group to coordinate our location
based on the availability of facilities because remember that
we have a number of facilities that were just simply destroyed.
Ms. DeGette. Right.
Dr. Franklin. The city of New Orleans, for instance, had
more than 10 operating locations and is now down to four. I
don't want to speak for Dr. DeSalvo, but I know that Covenant
House was a location that was under negotiation early on, had
to be worked through in terms of it as a permanent location. So
we have spent a lot of time working together to organize the
types of services we are going to provide, the communities we
are working in, et cetera, et cetera.
Ms. DeGette. But it still seems to me that we have huge
unmet needs and everything from psychiatric care to chronic
long-term care for cancer patients and diabetics and anybody
with long-term chronic issues. What kinds of plans are being
made to have a comprehensive system that is going to address
all of those issues? Dr. DeSalvo, did you want to talk to that?
Dr. DeSalvo. I do. We are trying to think beyond tomorrow
as you say, and so for example, we are trying to move beyond
sharing services like mammography, for example, where he is
doing that for us and think about how we systematize what we
are doing to create a medical home system of care, not just a
bunch of little medical homes that talk to each other.
Ms. DeGette. And how are you doing that, Doctor?
Dr. DeSalvo. We are doing that through PATH which is our
umbrella organization. So it is not a single entity, it is not
a governmental agency, it is a not-for-profit agency that is
run by the Louisiana Public Health Institute through which we
all participate. We have leadership there, administrative
leadership, but we don't really have the funds to systematize
ourselves. That is an issue which we are working on and sorting
that out.
But for example, sharing health information about patients
so that if a patient is at Vanges Clinic normally and works
maybe near my clinic and needs to pop in to get a follow-up, I
can access that record and the patient doesn't have to go back
to the clinic by their home. So really, we are making it easier
and more accessible for the patients.
We are also working together to begin to measure how well
we are doing care, what is the quality of care, how acceptable
are we so we have some idea of where the gaps are and how we
could improve.
And then we estimate. For example, we are running some
numbers we think that based upon the number of uninsured in the
city that just for that population alone we need to add another
30 physicians or so to get up to about 66 physicians. And we
are putting some price on that and trying to sort that out.
Where would we find that money and how could we grow together?
Ms. DeGette. Doctor you wanted to add to that?
Dr. Bertucci. Right now we are trying to set up medical
homes in our clinic also. Of course, with three and now soon to
be four physicians, that is extremely difficult. Part of the
problem is that we are not computer savvy, so we have four
physicians to treat 25,000 people. That comes out to one doctor
in about 5,000 people. So it is kind of hard to learn to use a
computer, and the computer actually slows us down initially
because it is a 2-year learning curve for this. You are going
to slow down five to seven patients a day. And with that it is
difficult for us to incorporate it when you are the only
doctors there. Where do we send those five to seven patients
that we are not going to be able to see?
But we did partner up with LSU as far as trying to get
some specialty help. At least they are trying to. This is the
plan, that we are doing investigations for a medical home, we
are trying to get a computer system and we have some
specialists to back up if we can do that.
Ms. DeGette. Dr. Fontenot, do you want to add to that?
Dr. Fontenot. Just to say that we have as the PATH group
surfaced sort of as the primary care group with its hospital
partner which historically has been Charity Hospital. But we do
include mental health providers and to provide true medical
homes, we are coming up with the same idea which is to look at
outcomes. Funding needs to follow the patient, but it really
needs to be predicated on outcomes and accountability. And I
think the group of people you see here in front of you,
including Dr. Bertucci, are really intent on proving that we
are providing quality care.
Ms. DeGette. Dr. Fontenot, I wanted to ask you another
question. I have got an article from Times-Picayune called
``Hospitals Run Out of Space, Emergency Room Patients Wait
Hours for Beds to be Available''. And this article is from last
week. I mean, it is not like from a month after the hurricane.
And it says things like Jack Fin says we are in crisis in New
Orleans, there is not a bed anywhere in the city, that it is
getting worse. As soon as a bed opens up it gets filled. I
wonder if you can talk to me why this is still going on and why
it is getting worse?
Dr. Fontenot. Well, in my humble opinion, part of the
problem is lack of access to primary care. Many of our patients
are showing up at our emergency department and our hospital
sicker with chronic medical problems because they have lost
access to their primary health care and primary care provider.
So part of the problem is certainly a lack of access to primary
care. We are trying to be part of the solution to that,
actually initiated our own primary care clinics in November
2005, have had some FEMA reimbursed trailers sitting on our
parking lot because of local bureaucratic red tape that are
intended to be placed in community settings as temporary at
least but to increase primary care access. These guys have been
doing a yeoman's job and doing the best they can, but they are
certainly at capacity; and I think if there is one thing we
could do immediately is open up additional primary care. But
the second step for that is when Dr. Bertucci identifies a
cardiology problem or an oncology problem, he has to have a
place to send those patients. And so specialty access is almost
as important or equally so.
Ms. DeGette. Yes, Dr. Bertucci?
Dr. Bertucci. I think the one other thing is that as we see
them in the physician's office, instead of them going through
the emergency room, we can make them direct admits. We can do a
history, physical, write the orders, and have that person
admitted. Sometimes it is just for observation. But we can
alleviate that emergency room admission so to speak by directly
admitting them to the hospital for observation with a
specialist that we have contact with. It is difficult. I mean,
we see very, very sick people right now. These are not the
normal people that we were seeing. The physicians, the primary
care doctors, we are out of our element a little bit in what we
are handling; but we are doing it because we are the only
people there. And when you go to send somebody to a specialist,
whether it be a bladder doctor, an orthopedist, whatever, they
are not there. You are talking about a 30- to 60-mile drive;
and we need to set up some type of coordinated system to get
the specialist back, along with the primary care, so we can do
the medical homes, we can do the electronic medical records, et
cetera.
Ms. DeGette. Are you all working under some kind of a
jointly--I know there was a plan developed which was submitted
to Secretary Leavitt and then he kind of rejected it and said
he wanted to go to this insurance program. But other than that,
is there any kind of long-term plan that you are all operating
on to--it seems to me what we need to do, we need to fully
develop the primary care system so that people don't have to
wait in line. Then we need a whole system of specialty care for
folks so they can have a place to be referred, and then we
still need to--and I am going to talk about this with the next
panel--we still need to get a safety-net hospital system in
place in the absence of Charity. So with all of that, is there
some kind of plan to do that, Dr. Fontenot?
Dr. Fontenot. Yes, I believe there is, and I think you have
described it quite articulately because you need the primary
care, specialty care, you need hospital partners to provide the
hospital-based services, the expense of MRIs, the CAT scans,
the surgical procedures that need to be done. And I think that
with PATH as a chassis that we can certainly build on that and
go forward. But we are certainly planning, have been, even
prior to the storm actually the PATH group existed. I have to
tell you at that point, it was a much looser coalition with
different agendas. I think that one of the bright spots of the
storm is that it has caused a coalescence I think of a group of
those of us who are committed to provide services to this
patient population.
Ms. DeGette. And just one last question. Do you think that
the primary thing the Federal Government can do is provide the
funding streams that you have all talked about or do we also
need to break some bureaucratic and regulatory barriers as well
to help you realize that plan?
Dr. Fontenot. I think you have hit it on the head. I think
additionally is to try to help figure out some incentives and
recruitment. I know that Dr. Cerise will probably be talking
later today about recruitment efforts and how we can increase
that because you will hear I think a person on this panel that
we really need providers.
Ms. DeGette. Thank you.
Dr. Wiltz. Can I summarize that? Local problems deserve
local solutions by local people using Federal money, if you can
send it.
Ms. DeGette. That is not always the way the Federal
Government feels, but thank you for sharing your view.
Mr. Stupak. Mr. Ferguson, 10 minutes, please. Dr. Bertucci?
Dr. Bertucci. I have to say this or I can't go back to my
parish. When you asked about the storm surge, the MR-GO was one
of our biggest problems, and obviously that is being addressed.
If I don't say that, they won't let me back in that parish.
Dr. Fontenot. Then you will only have three doctors.
Dr. Bertucci. Then we will only have three doctors, you are
right. So I just want you to know, we are working on that
issue. The storm surge that came, our levee system on the MR-GO
was 18 feet, supposed to be, high. Of course, erosion had made
it some 15. The wave that came through the MR-GO was 21 feet
high. Now, what happened was that wave came, yes, there was a
storm surge, but eventually it eroded through our levee system.
Thank you.
Mr. Stupak. Mr. Ferguson for 10 minutes.
Mr. Ferguson. Thank you, Mr. Chairman. I want to thank all
of our witnesses for your testimony today and your work to shed
some light on some of the challenges that we all face together
with regard to particularly the health care challenges post-
Katrina. I, like many, many other people, had an opportunity to
spend several days over that Labor Day weekend following the
storm just volunteering. We spent our time in Baton Rouge where
so many of the folks had been brought out. We actually worked
in a First Baptist Church in Baton Rouge where many moms and
their newborns who had been airlifted out of the city were
brought and there was--we have four little ones at home, so it
was a nice opportunity to help some folks with their newborns
and their little children and their families.
We also did some work at the River Center Shelter just
distributing clothes with some of the Red Cross volunteers. But
it really, for me just thinking back, just to that personal
experience, highlights really some of the health care
challenges that you all are working to try to help solve; and I
appreciate you sharing some of your experiences with us today.
I just want to pick up on a couple of comments that a
couple of my colleagues here have made and questions they have
asked, and I wanted to ask Dr. DeSalvo, if you could perhaps
elaborate a little bit further on the concept of the medical
home. I know Ms. DeGette talked about this a little bit, and I
am familiar with some of what you talked about in your
testimony; but could you maybe expand on that a little bit
further and maybe talk about specifically what you are doing at
Tulane with regard to this concept, this medical home concept?
Dr. DeSalvo. Medical home has actually become a buzzword in
health care nationally at a time when we needed something like
that to describe what we wanted to do post-storm. Before the
storm we all really had an approach to this through the
hospital-based care and very siloed care. So physician, and
then you needed mental health, and then you referred elsewhere.
A medical home is really a change in that approach. It is
an approach to care where multidisciplinary teams that are
generally led by a physician have a relationship with the
patient. And so the values that that medical home has for
things like patient-centeredness which includes cultural
competency but also quality and helping patients self-manage
their chronic disease and then using health information
technology to support care. So to share health information with
all the other providers, taking care of that patient, with the
patient themselves so they can understand their medical issues,
and then to do things like clinical decision support so that if
we forget to order something that is evidence based and
preventive, the computer if you will helps us remember and work
with the patient to make them better. So it has some essential
components of team-based care management supported by health
information technology, and it also encompasses this idea that
it is very accessible to the patients; and for us in New
Orleans, that definitely means geographically accessible, hence
the map. We have been using these maps since the early days to
really visually see where we actually have placed care in our
city, where the lights are coming back on and people are coming
home, and where we think we might need to put new medical
homes. It is insufficient by itself. They have to be linked to
each other and then to secondary level care, specialty care,
and then to a hospital when necessary. But it really should be
the multidisciplinary entry point for the patient into the
system.
Mr. Ferguson. Chairman Stupak was talking a little bit
before about the funding that is available through the Deficit
Reduction Act and that some of those monies are still there.
They are sitting there, they are not spent yet. In your
estimation, what things can we be doing to help folks like you
and your colleagues access some of these funds?
Dr. DeSalvo. On our back-of-the-envelope calculations that
we have been doing at home, we think there is sufficient money
in the Deficit Reduction Act's allocation, and there is a
category 5 the GAO reports about which is--at least when the
report came out was about $136 million that could be used to
restore health care services, but I don't have any policy
experience. It seems to me that that is a sort of bucket of
money we could use, and it would go a really long way because
primary care is incredibly inexpensive. And that sort of money
has already been allocated if you will and there are already
providers over here trying to do the right thing, and we just
need to put them together. In fact, we even have the mechanisms
for the money to flow because of the SSBG, the Social Services
Block Grant. We spent many months making contracts and
relationships from the HHS to the States to a quasi-
governmental agency which then allocated it to the PATH network
through the LPHI so that each of the clinics could then benefit
from funding based upon a pretty rigorous budget that we put
together. So there is already a mechanism through which we
could allocate those funds.
And if I could, I think the idea is if we don't do that, if
we don't provide some bridge support for these clinics, we are
going to go away. We are going to crash. And then we are going
to go back to a system that was not working well for us which
was using a lot of emergency rooms for care. And so it is a
really important opportunity.
Mr. Ferguson. It also seems like you have got a model that
seems to be working. We have some funding available which could
help it work, continue to work well. It would be tragic if we
couldn't get our act together here collectively. Did you want
to add something to that?
Dr. Bertucci. Yes. I saw a sign and it said get well soon.
And it said, we prefer, stay healthy longer. So I think that
preventative medicine is a big thing.
The only problem I saw with the medical home because I am a
dinosaur primary care doctor who was raised by, see a patient,
make some money, see a patient, make some money. And it is hard
now to break into the system that the idea of this is that you
are not paid by patient contact but by outcome, by trying to
prevent the patient from coming in the hospital. You save
money, everybody makes more money. It is difficult for me to
conceive.
The second problem is that primary care doctors, we are
people doctors. We like seeing patients. If somebody sat there
and said you don't have to see 40 patients anymore, I would
say, I like seeing 40 patients. I mean, I like people and I
like patients. So it is hard for me to delegate that out to
other ancillary people, but that has to be learned.
You have an opportunity now as you change the medical
schools and everything else to train these people number one,
with electronic medical records. I never used the computer
until the hurricane, and I am much better at it. I actually
made a power point but I got it here too late. But you can
learn. We are teachable, OK? But the students come and these
are the people that you have got to teach these concepts if you
want them to work. The only thing I fear and let me tell you, I
am a firm believer in patients taking responsibility for their
illness; and when you get so many ancillary people involved,
sometimes I worry that the patients start to depend on them and
not take responsibility for their disease. So that is just
something we can watch and we can learn, too.
So I see a good benefit to the medical home, I see a great
benefit to the electronic medical record, and I think it will
work but we need to really start with a training situation and
bringing the people out and training the primary care as they
come in.
Ms. Rowland. Mr. Ferguson, I think it is important to note
that while everyone is talking about building capacity, putting
community health centers in, that those centers rely on
financing and ultimately just sending appropriated dollars to
run those centers isn't what keeps them going. What actually
keeps them going is to provide health care coverage that some
of the patients in those centers actually have health insurance
paying for their care.
Today the average community health center receives more of
its revenues from the Medicaid program than from the Public
Health Service Grant dollars because they are seeing about
three-quarters of their patients with Medicaid coverage and a
quarter who are uninsured.
So I think looking at the Louisiana situation as just an
issue of putting public health resources on the table is not
going to sustain these clinics over the long run. They really
also need to address their tremendously high rate of
uninsurance.
Mr. Ferguson. I have got a minute-and-a-half. Go ahead.
Dr. Franklin. The short term issue is so critical, I would
like to remember everyone in this room the importance of the
short-term issue. Our health fairs would not have been such a
success, Operation Blessing would not be as busy as it is
unless we had thousands of people who needed health care today,
tomorrow, the next day. So a one-size-fits-all solution is not
where we need to be today, tomorrow, and the next day.
Clearly we have all worked to goals to improve our ability
to respond to outcomes, provide information regarding outcomes,
et cetera, but you can see before you a number of different
types of health care providers, different times in our careers,
different skill sets in terms of providing the care to
patients, different solutions for different organizations.
And so I would like to emphasize to this committee just
having a community health center approach is not enough. We
need all levels of approaches to the solution.
Mr. Ferguson. Thank you very much. I yield back, Mr.
Chairman.
Mr. Stupak. Mr. Walden.
Mr. Walden. Thank you, Mr. Chairman.
Mr. Koehl, you indicated in your opening remarks that you
have seen a 48 percent increase in the death rate in New
Orleans.
Mr. Koehl. Those numbers come from Dr. Kevin Stephens'
office, a 48 increase per capita in the death rate post-
Katrina.
Mr. Walden. Now, I guess the question that comes to mind is
a lot of people fled New Orleans and did not come back. Is part
of the reason there is a higher death rate is those who were
sickest couldn't leave and are there? I mean, what are the
contributing factors? That is such an astounding increase in
the death rate.
Mr. Koehl. Lack of primary care seems to be the major
issue, and without the lack of primary care, you don't have a
doctor a year ago telling you that you had high blood pressure.
Mr. Walden. Right.
Mr. Koehl. So what happens is you present yourself in a
clinic situation with a heart attack when a year ago one
prescription of a diuretic possibly and another hypertensive
medication would have prevented that heart attack. So the lack
of primary care for the last 18 months has exacerbated this
problem greatly.
Mr. Walden. So the makeup of the population has remained
similar?
Mr. Koehl. For the most part except this population is now
uninsured and doesn't have anywhere to go for primary care.
Mr. Walden. They don't have the access.
Dr. Bertucci. I think the other thing you have to realize
the amount of stress these people were living under.
Mr. Walden. I can't, no.
Dr. Bertucci. Stress will exacerbate every disease entity
you have got, whether it be diabetes, coronary artery disease,
it makes no difference. As we loaded people off the roof of the
hospital into the boats, they didn't say boo. When we put them
in helicopters, they were all in shock. And as you sit and see
patients now, even the stoic patients--I mean, these are guys
that worked in business offices, lawyers, everybody, they are
getting depressed because they are exhibiting what I call
emotional fatigue.
Mr. Walden. Sure.
Dr. Bertucci. They used up all their reserve energy and now
they can't handle and cope anymore. So I think stress is a big,
big part besides lack of access to care. Stress and dealing
with everything that--they have got to deal with insurance
companies, they have got to rebuild their homes, they have got
to get a new job, they have got to handle--all their families
are displaced. When you sit down with a family, all these
families live together now. You go and you say, well, where is
your mom? Well, they all moved. They are all over. I mean they
are in four different spots when they used to be within two
blocks of each other.
Mr. Walden. I had to step out of the room for a few
minutes, and I don't know if you answered this but you raised
an issue, Dr. Bertucci is it about your inability to get an SBA
loan. Why? That is what I don't understand.
Dr. Bertucci. What had happened is my partner would not
come back. So when I went to the SBA, they said, well, your
partner has to sign that he will take the SBA loan, too. I
said, well, he is not coming back. And I said, so what do I do
about that? I had to go get his name removed and everything
else. Then when I reapplied, again this is what I was told. I
am not a bad credit risk. I was number one. I don't owe any
money, and sometimes these SBA loans are forgiven. And I said,
well, I don't want it forgiven, I just want a low-interest loan
so I can rebuild my office. And this has been five appeals
worth and the papers must be this high. We have jumped through
every hoop that they have asked us to do, and we don't have
that money.
Now, I am working with the Franciscans, and I am very happy
with them so I don't want them to think I am going to go build
an office and move away. But the reality, and I am sure other
doctors are going through this same situation, and we need that
monies and we also need some monies for people that weren't
there before the storm that may want to come back, some low-
interest loans to help them build a building, not just the ones
that were there before. And they need to speed it up. The red
tape is a killer.
Mr. Walden. I guess that is what stuns me in the course of
this hearing today is the fact you still have people, I assume
from these videos, that are showing up the night before or 5 in
the morning or whatever and waiting in lines and yet don't I
recall that there was a lot of money sent out before the DRA
for DSH payments like to Charity Hospital? I think Dr. Burgess
indicated it is like a quarter-of-a-billion dollars was sent to
Louisiana? What has happened to that money to help in this?
Dr. Fontenot. Well, remember that the DSH money that flowed
to the hospital only flows if service is provided, not a free
check.
Mr. Walden. I got you.
Dr. Fontenot. So having been out of the hospital business
for a period of months, immediately post storm we reopened
clinics, started the tents that you saw in the parking lots,
and talked with CMS about whether there would be some
reimbursements because these are not licensed facilities.
Remember, we have never been through this before. These
were medical tents.
Mr. Walden. Hard to have joint commission come and do their
evaluations I assume?
Dr. Fontenot. Exactly. Then we actually got back into the
inpatient business temporarily for the trauma facility and a
leased facility in an adjacent parish and actually just opened
portions of University Hospital in November. Some of those DSH
monies now over the last year have flowed to other hospital
institutions who have been providing care. So there has been
DSH money flowing, it is just not all been directed to the
public hospital system.
Mr. Walden. OK. And I guess what I would like to sort out,
too, I mean, we have obviously voted to send a lot of money. I
have. I am from Oregon. We don't get hurricanes thankfully. We
have forest fires and a few things, but they are not as
devastating to people and communities generally. I guess what I
am trying to figure out, we have allocated a lot of money. What
sort of impediments do you have to be able to access that and
do some of those--are there issues like that the State needs to
do something, ask for something that are holding up
distribution of the money?
Dr. Fontenot. I think that in panel 3. Dr. Cerise is going
to be speaking to you about that----
Mr. Walden. All right.
Dr. Fontenot. And that probably would be better left to him
for discussion.
Mr. Walden. So none of the rest of you have any ideas on
that? Dr. DeSalvo? You are smiling. You just don't want to say.
Dr. Bertucci maybe?
Dr. Bertucci. I think that we need more access to the
Louisiana Recovery Authority so that we can get some of our
community block grant money for buildings and structures. The
infrastructure seems to be a taboo. Everybody says don't ask
for this, don't ask for that. You are asking us what we need,
and so we have said we need funding and we need buildings and
we need a hospital in St. Bernard. The infrastructure, when you
come to buildings, brick and mortar, everybody goes don't do
that----
Mr. Walden. But if we get back to what Dr. Fontenot said,
you don't get DSH payments without a facility in effect, right?
So you don't get the money to pay for the services if you don't
have the bricks and mortar for the physicians to come back to
and the nurses and everybody else that we need. Seems to me the
first thing you do is establish some sort of physical facility
so you can call it a hospital and then be able to practice
medicine. You know, we do this in other emergencies around the
world. If it is tents, it seems like you would call out the
National Guard. I don't know.
Dr. Fontenot. Or begin to allow DSH money to cover formerly
unallowable costs, specifically physician costs. Those
historically have not been covered for the public hospital, nor
for any other health care provider. So that certainly is an
option.
Mr. Walden. OK. Ms. Rowland?
Ms. Rowland. You know, often it sounds like the DSH program
is a block grant which has flexible spending under it; but the
DSH program actually was set up to provide additional payments
for public hospitals when the Medicaid reimbursement formula
was changed. So it has to be at least linked to direct-patient
care. And I think you are right that one of the things we could
look at as a better way of dealing with emergencies such as
this is to have some more flexibility in terms of how quickly
DSH funds could be reallocated. But the real funds that we keep
talking about are discretionary, both the Social Services Block
Grant and then in the DRA there were additional funds set up
that were discretionary funds that could have been used.
Mr. Walden. And where are those monies now?
Ms. Rowland. Those have not yet been expended according to
the recent report that just came out from the GAO. Those funds
have been set aside and not yet expended.
Mr. Walden. By whom?
Ms. Rowland. By the Department of Health and Human
Services.
Mr. Walden. So DHS has those monies that we authorized, and
they have not gotten to Louisiana?
Ms. Rowland. It was $2 billion and they used about $1.5
billion to allocate out for the Medicaid waivers that were
given to the States where people were evacuated to and to
Louisiana itself, but they also had a section V they call it
which allowed for grants to be made to develop access to care
and resources, and those have not been fully expended.
Mr. Walden. $1.5 billion of the $2 billion has been?
Ms. Rowland. And those were paying for the medical care
costs of individuals either on Medicaid in Louisiana,
Mississippi, Alabama, and the evacuees or for uncompensated
care in those States.
Mr. Walden. OK. One final question because again, I get
asked this stuff in my district and I have supported the
emergency relief and all. But one of the questions that
consistently comes up is, are you spending our tax money to
rebuild buildings that are going to get blown away in the next
hurricane or flooded out? What is the answer I should give? I
know at Charity Hospital I think I heard this morning that--or
maybe it was you, Dr. Bertucci, that said somebody was offering
ground that would be 8 feet higher but don't I recall the flood
of your building was 13 feet? So you are still 5 feet under
water.
Dr. Bertucci. Well, yes. Actually what is going to happen
is it is 8 feet higher, and the hospital will be built up 8
feet. So you are talking about 16 feet. So I think that is No.
1. Second, the floods that have occurred, if you look,
obviously are on a 40-year type of a term. Well, you had the
what, 1927 flood, rise in tide. You had Betsy in 1965, and then
you have Katrina. I am not saying that we don't want to prepare
for that, but the reality is that we can--if they fix the MR-
GO--we didn't flood from the hurricane, we flooded from the
levies breaking. So if we could fix the MR-GO, raise the levies
up to what they said they were going to fix, we should be able
to weather those type of storms. Now, there is no guarantee.
That is why I think it is hard to recruit people to this area,
number one, to live in what were are living in, two, to
practice in the situation we are practicing in. Without
facilities, it is impossible. The people, though, amazingly,
multigenerational, they want to come home. And with the
hospital you are going to get your elderly people back, you are
going to get your specialists back--you can't get the
specialists without the hospital and without the old people, I
mean, nice old people.
Mr. Walden. Mr. Chairman, I know my time has expired. I
just wanted to say thank you for what you do in your
communities. The commitment you all must be adhering to is hard
for us to really fully appreciate I think unless we were on the
ground there. So thank you and your colleagues for what you do
to try and improve the health care and the lives of the people
of Louisiana and the Gulf Coast. Thank you, Mr. Chairman.
Mr. Stupak. Thank you. Mrs. Blackburn, I understand you
want to pass on this panel until next panel? One question? Go
ahead.
Mrs. Blackburn. Thank you, Mr. Chairman, and I want to
thank all of you. I appreciated the attendance and the interest
when we did our first hearing in Louisiana last year to follow
up on this issue. And Mr. Walden was on the line of questioning
where I want to go, and I do have questions for Dr. Cerise when
he comes about the funding. And I want to clarify that I am
understanding right. Ms. Rowland, you are saying $2 billion was
appropriated, $1.5 billion has been spent?
Mrs. Rowland. Well, $1.5 billion was actually allocated out
and the States are filing claims against it, so it hasn't
totally been spent but it was allocated to the States.
Mrs. Blackburn. All right. And the section V money is not
fully expended is what you were saying?
Ms. Rowland. Correct.
Mrs. Blackburn. OK. I wanted to seek clarification on that,
and then Dr. Bertucci, I think you said the LRA, you all were
having trouble accessing the funds via that?
Dr. Bertucci. Actually I met with the LRA subcommittee, and
again I am not supposed to get controversial but what I was
told was that medicine was not a priority when we met. They sat
down and a survey in the beginning of the hurricane and said,
what are the needs? What would make you come back?
Mrs. Blackburn. OK.
Dr. Bertucci. Now, what made them come back were levies,
jobs, housing. So that is very important. So they did put those
ahead of us--police, schools, churches, fire, medicine. So we
were told as we met that the reason that we had not been there
was that medicine was not a priority. Now, I am assuming we are
a priority now, and I am hoping after this meeting we get some
access to them. The problem comes that we are being told now
that maybe the infrastructure monies that they had were already
delegated out to other hospitals and different other
situations.
And I want to say one thing real quick. Thank the United
States of America and all of you and everybody who sent
donations down here to help us through this. Louisiana greatly
appreciates it.
Mrs. Blackburn. OK. And then of you all who are practicing
medicine, how many of you are practicing in a brick-and-mortar
facility? OK. All right. And then the Operation Blessing, is
that in a brick-and-mortar yet?
Mr. Koehl. No, it is not.
Mrs. Blackburn. It is not? OK. So that is still in a
temporary or a tent?
Mr. Koehl. No, it is mobile units brought together----
Mrs. Blackburn. In the Wal-Mart?
Mr. Koehl. No, we are not in the Wal-Mart.
Mrs. Blackburn. OK.
Mr. Koehl. We are East Orleans on Reed Boulevard.
Mrs. Blackburn. All right. Thank you.
Dr. DeSalvo. Mrs. Blackburn, for clarification, our clinic
was a men's dorm that we are renovating. It is not really a
clinic though we are in it and we have air-conditioning.
Mrs. Blackburn. Now, has the Health Care Authority in
Louisiana going to change their process on how they permit? I
know they were giving permits even though you all had your
generators and your storage in the basements, and they were not
supposed to be doing that. They were supposed to be on the
fourth floor. Have they changed the way that they are going
about giving the permitting? Does anybody know?
Dr. Wiltz. The State enacted a new building code to all new
construction, so all new construction has to meet----
Mrs. Blackburn. New construction, right?
Dr. Wiltz. Yes.
Mrs. Blackburn. OK. Thank you for that.
Dr. Fontenot. At Charity Hospital it is important to
remember that our switchgear is still in the basement. FEMA
will not allow you to rebuild anything that is not out of the
flood plain without mitigation, et cetera. But they do require
with our repair of University Hospital back to its previous
status that we provide some asset protection which will include
a little flood wall to keep water from getting into the
basement. But again, they only allowed that because it is
considered a temporary facility.
Mrs. Blackburn. OK. I know the State of Louisiana was self-
insuring. Have they changed that process so that they are no
longer self-insuring their infrastructure? Dr. Wiltz, do you
know that? If not, I will ask Dr. Cerise on panel three.
Dr. Wiltz. No, I do not know that.
Mrs. Blackburn. Nobody knows? OK. Thank you, Mr. Chairman.
Mr. Stupak. Thank you. On behalf of the full committee,
thanks for being here today and helping us out. We look forward
to continuing to work with you. This will not be the last
hearing. It will not be a year. We will keep the pressure on,
and you will be seeing a lot of us. Thank you for coming.
Dr. Wiltz. Thank you.
Mr. Stupak. We are looking forward to hearing from our next
panel. Dr. Alan Miller, interim senior vice president for
Health Services, Tulane University Health Sciences Center; Mr.
Gary Muller, president/CEO, West Jefferson Medical Center; Dr.
Pat Quinlan, CEO, Ochsner Health System; Mr. Leslie Hirsch,
president/CEO, Touro Infirmary; and Mr. Donald Smithburg,
executive vice president/CEO, Louisiana State Health Care
Services Division. If those folks would please come forward?
Gentlemen, as you know, this is Oversight and
Investigations hearing of the Energy and Commerce Committee. We
swear-in all of our witnesses.
[Witnesses sworn]
Mr. Stupak. Thank you. The witnesses are now sworn. We will
start with Dr. Miller. We have your testimony. If you would try
to summarize it there in 5 minutes that would be of great help
to us, and thank you for being here.
STATEMENT OF ALAN MILLER, PH.D., M.D., INTERIM SENIOR VICE
PRESIDENT FOR HEALTH SERVICES, TULANE UNIVERSITY HEALTH
SCIENCES CENTER
Dr. Miller. Thank you for the opportunity to speak about
the state of health care in the New Orleans region 18 months
after Katrina, and Tulane University's role in the recovery.
Since Hurricane Katrina, we have seen enormous progress in
some areas, in other critical areas we have seen shockingly
little progress resulting in a stalemate that will make reform
more difficult and threaten the existence of our training
programs.
I want to thank the committee members for your support for
the region. I am Alan Miller. I represent Tulane University, an
institution of higher education that not only provides health
care but also trains our future doctors. The past year-and-a-
half has been challenging for everyone in New Orleans,
especially those of us trying to rebuild the broken health care
system, provide care, and train physicians. Tulane University
Health Sciences Center suffered losses of greater than $200
million in property damage, lost research assets, and revenue.
Through the storm and since, Tulane, the largest employer in
Orleans Parish, has continued to do exactly what it has done
since 1834, provide health care, educate physicians, and
advance medical knowledge.
When Katrina struck, it left our medical students,
residents, faculty, and staff scattered across the country. In
3 weeks, a medical school for Tulane students taught by Tulane
faculty was up and running at the Baylor College of Medicine,
and our residents were placed in training sites in Texas,
Louisiana, and throughout the country.
By July 2006, there was a 51 percent reduction in the total
number of physicians filing claims in region 1. Loss of
clinical faculty at Tulane and LSU not only decreased the
available physician workforce but reduced the clinical faculty
needed to teach future physicians. With the public hospitals
down, care for the uninsured has been assumed by private
hospitals and physicians. State Medicaid DSH has historically
been directed to the safety-net hospital system. With the
closure of Charity, there remains a major gap in funding that
care. Since Katrina, Tulane faculty has provided $6.8 million
in uncompensated care, and we have absorbed $5 million in
unreimbursed training costs. Despite this, Tulane has retained
faculty by guaranteeing salaries through June 2007. In effect,
a private, non-profit educational institution has been using
its impaired and limited financial resources to underwrite
health care and graduate medical education and help preserve
the health care workforce. Tulane cannot continue to do this
and survive.
In order to preserve the physician workforce, we need
immediate funding for providing care. Approximately $30 million
per year is needed to provide basic reimbursement to area
physicians for uncompensated care. We ask that you consider a
mechanism to provide funding directly to providers. We ask that
Congress consider a grant program to provide incentives to
recruit clinical faculty to teaching institutions in the
hurricane-affected region, for loan forgiveness, relocation,
and bridge funding.
Additionally, there must be a focus on the future of GME.
This is a long-term issue but requires immediate attention.
Teaching faculty and residents provided a large portion of the
care for most underinsured patients in the U.S. Moving medical
education to the front burner of health care redesign is
critical. Some look at medical residents as moveable parts that
could be rearranged to maximize CMS reimbursement. This is far
from the truth. Issues of program interrelationship, critical
mass, and quality educational experience must be considered or
accreditation will be at risk.
Pre-Katrina, Tulane trained 520 residents. At any one time,
240 of those residents were on rotation at Charity. Today
Tulane trains a total of 327 residents. Special CMS waivers
were required to allow residents to continue their training at
new sites. Protracted negotiations took place requiring Tulane
to hire outside counsel simply to navigate the process. This
should not be allowed to happen in future disasters.
Katrina revealed a major flaw in the way we fund GME. When
Katrina hit, the medical schools were left with the
responsibility for resident-in-training and salaries but were
unable to seek reimbursement from closed hospitals and most
cases the hospitals that accepted them.
For the protection of all but most critically that of the
trainee, medical schools must have greater control over both
training and funding when a disaster results in total or near
total closure of a teaching hospital. We ask that the
committees consider a hearing to specifically deal with the
issues surrounding GME. In addition, Tulane offers to host a
panel of all stakeholders to re-evaluate resident training and
financing when disruption of training occurs.
Of critical importance to our medical schools is the New
Orleans VA Hospital. Pre-Katrina, Tulane faculty and 100
residents provided 70 percent of the patient care at the VA.
Outpatient clinics have reopened in the downtown location where
there are 26 Tulane residents and visits are up to 75 percent
of pre-storm. It is essential to re-establish a hospital in
downtown New Orleans. Veterans have expressed a strong desire
to have their care resumed by their physicians and the system
that has served them well. The facility must remain proximal to
the medical schools so that highly skilled Tulane and LSU
physicians can provide state-of-the art care.
The gridlock we find ourselves in is destructive, both
short and long term for our hospitals, medical schools, and the
public we serve. The time has come for all to set aside their
differences, share vital data, and have an objective party lead
constructive negotiations.
We have many challenges to overcome. With the support of
the American people and leaders such as yourselves, we will
recover.
Thank you again for your time and support.
[The prepared statement of Dr. Miller appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you, Dr. Miller. Mr. Muller, please, for
5 minutes.
STATEMENT OF A. GARY MULLER, PRESIDENT/CEO, WEST JEFFERSON
MEDICAL CENTER
Mr. Muller. Mr. Chairman and members of the committee, I am
Gary Muller, president and CEO of West Jefferson Medical
Center. I am grateful the committee has expressed a continued
interest in the worsening state of the health care system in
the New Orleans region.
West Jefferson Medical Center, located 10 miles from
downtown New Orleans, is a 451-bed public community hospital
and health system with programs and services across a complete
continuum of care. West Jefferson was one of three hospitals
that did not close after Hurricane Katrina and is now one of
the eight safety-net hospitals serving all patients.
Pre-Katrina we were projecting an $8 million profit in
2005. When I testified before this committee January 2006, we
had incurred operating losses of $30 million. I come to you
this time with a heavier burden of $48 million in operating
losses.
Recruiting nurses and physicians has become a near
impossibility, and the supply and demand of the entire health
care workforce has reached a crisis. Prior to Hurricane
Katrina, we spent a total of $2 million annually on agency
nurses. Currently we are forced to spend $1.1 million each
month which was $13 million in 2006. It is extremely difficult
even to have a physician visit our city for the possibility of
working there.
Certain financial commitments are necessary to sustain
hospital operations in our area. The 2007 Wage Index update
that was effective October 2006 was based on wage data from
Medicare Cost Reports beginning during fiscal year 2003. Thus,
there was almost a 3-year lag between the data being used to
develop the wage index and the actual implementation of the
wage index that incorporates the data. Under the CMS
methodology for incorporating changes, our index will not begin
to reflect the changes we have experienced in labor costs until
October 2008. I am requesting that you consider a special wage
index adjustment for hospitals in the affected area to help
offset some of the losses.
West Jefferson is supportive of the CMS Medicaid proposed
rule on intergovernmental transfers and certified public
expenditures. As we understand the proposed rules, CMS will
require States to direct Federal funds directly back to
governmentally operated health care providers. This certainly
seems aligned with how the Federal Government intended these
funds to be used in the first place. For West Jefferson, we
believe this will result in equitable distribution of funds
directly to our hospital without going through the State. We
worked diligently to offer language to the Stafford Act that
would qualify hospitals as eligible recipients of the community
disaster loan program. With hard work of our entire delegation,
we were successful in securing that funding. It was vital for
our hospital in the few months following the storm, and we
incurred substantial financial losses.
Both the House and Senate appear to be on the verge of
floor action to permit the forgiveness of CDL which has been
the practice pre-Katrina. I strongly ask for your support to
give these loans their currently obligated payback and we
cannot do that.
We have implemented an operations improvement action plan
whereby approximately $8 million of savings or revenue
enhancements have been identified at West Jeff. Most of the
cost savings center on reducing agency nurse costs which
included only two nurses pre-Katrina and grew to 92 agency
nurses that we employ presently. We have also improved
efficiencies so that the emergency room can flow better with
the increase in patient volumes. West Jeff also supports two
federally qualified health centers in our service area to
support the medical home model that you have heard about
earlier.
One day last week, we were simply overwhelmed with 32
admissions waiting in our emergency department. Simply put,
every available bed in our hospital, which was 55 more than
pre-Katrina, was occupied; and we had 32 admitted patients
waiting on stretchers in the hallway of the emergency
department. Our ambulances and our paramedics routinely wait
with these patients which takes these guys and ladies off the
streets to serve the patients in need.
Unfortunately this is quickly becoming the norm as there
are simply not enough staffed beds in the New Orleans region to
care for the volume of patients. We put in a phone call to the
Department of Health and Hospitals, and the next day the
Secretary, Dr. Cerise, was at our hospital offering assistance
and potential solutions. He has also been helpful with his
support of the uncompensated care pool that was developed at
the State level to offset some of our growing indigent care
costs. He is also responsive to West Jefferson's plan to open
12 more mental health beds by funding them. Nevertheless, the
shortage of beds, particularly psychiatric and acute care, is
at a critical point; and more funds would allow us to open more
beds.
However, I remain optimistic that our issues will
eventually be resolved by both public and private hospitals,
community clinic providers, payers, and governmental officials
at the State and Federal levels to provide a united solution in
the new model that will improve care for all citizens of
Louisiana. I have great faith that our Federal and State
leaders will not abandon us. Together we can make a difference.
Thank you very much for your time and your interest.
[The prepared statement of Mr. Muller appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you, Mr. Muller. Dr. Quinlan.
STATEMENT OF PAT QUINLAN, M.D., CEO, OCHSNER HEALTH SYSTEM
Dr. Quinlan. Thank you, Mr. Chairman. I want to thank you
and the committee and other Members of Congress who have
actually come to New Orleans. You have to see it to begin to
understand it. Seeing is beginning to believe. I want to remind
everyone, whatever you have seen, you have only seen a small
part of it; but we appreciate your interest.
Particularly after speaking with your staff, I think this
effort will make a difference; and I personally am very
hopeful. There is much to be done. Many people have worked
together to answer the kind of questions that you have raised
here.
I would like to tell you a little bit about us. We are
Ochsner Health System, an independent, non-profit organization
made up of seven hospitals and 32 clinics, employing about
8,400 people. We are the largest private employer in the State
of Louisiana. We have as a result borne much of the brunt of
this storm. It is also of historic interest I think for you to
know that Alan Ochsner, our namesake, made the first connection
between smoking and lung cancer; and for that he was ridiculed
by the medical establishment.
We are one of only three hospitals. Our other two sister
hospitals in Jefferson Parish took care of the patients during
the storm. We have been on the point since the beginning. We
have done this despite ongoing interruption of our care during
and after Katrina, and we have cared for everyone who came
through the doors. Importantly we are located just a few
hundred yards from Orleans Parish border, so sometimes the
discussion gets a little misleading for people who don't know
the geography.
We made the decision to stay open because simply that is
our public duty to do it. Since Hurricane Katrina, Ochsner
professionals have quietly gone about the business of taking
care of thousands of people despite the fact of receiving
significant damage to our facilities. We have been diligent in
restoring our facilities and moving ahead with the idea we will
just keep going until we run out of gas because so many people
depend on us.
We also had to provide food and shelter for our staff as
well as pay them for their increased long hours during this
time. Our extensive disaster preparations played a major role
in our ability to mitigate its damages and our ability to
provide full services, even under emergency conditions, and
this preparedness allowed us to continue to meet the needs of
the community. As short-handed as they are, I think it would
have been much worse if we had not been prepared.
We have had numerous and extensive financial losses that I
think were, for the purpose of brevity, were covered in our
submitted testimony.
I would like to tell you about clinical care. It is
something that I think is at the heart of the question here. We
currently employ over 600 physicians and about 130 mid-levels.
That is about 750 people who take care of people directly and
importantly receive no direct care for taking care of patients.
That is one reason we bear a disproportionate share because we
have this large group.
We don't seem to fit the standard stereotype I think what
you think of in medicine. We are basically everything. We are a
large academic institution. We are a large ambulatory system
and we are also a hospital system. Basically our Government is
not prepared to deal with organizations like that, the kind of
organizations actually you need most during a crisis.
We are one of the largest private, non-university based
academic institutions in the country with over 350 residents
and fellows. We have about 70 guest residents from Tulane and
LSU. We provide advanced research, translational research, and
conduct hundreds of clinical trials. In addition, we provide
training for over 400 allied health students. These are the
folks who make hospitals run--as well as over 700 medical
students from both LSU and Tulane with little or no funding to
support that mission.
The importance of Ochsner's graduate medical education
program has increased greatly since Katrina because we are the
only fully functional academic center in New Orleans right now.
We currently have done everything we can to support our
schools. We want them to come back. They are important for our
future as a State. We know that a significant number of
physicians locate to practice where they train, and we are
training the next generation with our colleagues.
The sad reality is we are bleeding red ink as a result of
holding this fragile health care system and medical education
system together. We are caught in the middle of an inflexible
bureaucracy. Basically we have State, local, and Federal
Governments living off of our balance sheets at the moment; and
we can't do it much longer.
Simply put, well-intended money to help us as providers is
not reaching us on a timely basis; and when it does, it is
insufficient to meet our needs. Basically, we put the company
on the line to do the right thing and the bet is still out.
Despite our efforts at retention, we had no layoffs; we have
laid off no one. We still lost over 2,000 employees and more
than 100 physicians after the storm because people just decided
they had had enough. As a result, we are experiencing a
shortage of highly trained physicians, nurses, and support
staff. Recruitment and retention continues to be a major issue
for us. We are spending $20 million annually in employment
agency fees to staff critical areas to stay open. We are losing
money to stay open and meet the public need. Our wages have
increased close to 11 percent. While our health care system
costs have increased almost 11 percent, the Medicare wage index
decreased almost four percent; and the difference is something
we cannot sustain.
To attract talent, we need to cooperate, to operate, and to
increase our profitability as wages increase as well; and we
have been unable to do that. A permanent fix, as Gary
mentioned, to the Medicare wage index would be most helpful in
addressing this issue of sustainability.
In 2006 the Ochsner Clinic was forced to increase physician
salaries by $6 million or 5 percent, and we anticipate a
similar increase this spring.
In addition, we are often forced to pay significant
recruitment bonuses to attract staff at all levels. We are
committed to remaining full capability until the end.
Ochsner Health Systems also faces a $4.4 million in
outstanding unemployment claims despite the fact that we had no
layoffs. This is an issue between the State and us and the
Federal Government, and in my submitted testimony, we have a
suggestion in mind.
Funding for uncompensated care is also an issue for us.
Ochsner has done more than its fair share for caring for the
uninsured in the region. We have seen over 40,000 patients in
our system, and our inpatient costs alone cost over $25.5
million. We have been reimbursed about $12 million for that.
Please note that I am referring to costs and not charges, and
these refer to hospital services only and does not address our
clinic load.
With over 1 million clinic visit a year and over half of
our revenue coming from physician services, our approach is
simply not understood by government at all levels. We are more
than a hospital system, we are a medical system. Our uninsured
and Medicaid volumes have increased 50 percent from pre-Katrina
levels. The time between providing the care and receiving
reimbursement has become excessive. We recommend that money for
reimbursement for the care of the uninsured follow the patient
directly and not go through multiple parties in order to
expedite these funds receiving providers of all kinds on a
timely basis. Predictable funding is absolutely essential to
predicable access for patients as you heard from the previous
panel. And access is at the core of good medical care.
I would like to talk about our efforts to expand capability
and the retention of health professionals.
Mr. Stupak. Could I ask you to summarize a little bit
there? We are way over.
Dr. Quinlan. Yes.
Mr. Stupak. Thanks.
Dr. Quinlan. OK. Basically we have a lot to do. We have
acquired new hospitals, some of which were in the news for
failing and we will need some help in restoring those to make
sure for the next crisis that they will be there. And also for
the professionals who depend upon them for the livelihood. They
will have a place to work and a place to stay.
I would like to say just in closing, I think the promise
of ongoing supervision and collaboration with this committee
will make all the difference between what we had before and
what we will get in the future. Thank you for your efforts.
[The prepared statement of Dr. Quinlan appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you, Doctor. Mr. Smithburg, please, for 5
minutes.
STATEMENT OF DONALD R. SMITHBURG, EXECUTIVE VICE PRESIDENT/CEO,
LOUISIANA STATE UNIVERSITY, HEALTH CARE SERVICES DIVISION
Mr. Smithburg. Chairman Stupak, Ranking Member Whitfield,
members of the subcommittee, I am Don Smithburg, CEO of the LSU
Health Care Services division which comprises most of the State
public hospitals and clinics that serve as the public teaching
system in Louisiana. I also represent the facilities that Dr.
Fontenot showed you in her brief video during the first panel.
Many members of this subcommittee, as well as a delegation led
by Representative Clyburn, took time out to travel to New
Orleans several times to survey the devastation. I have had the
privilege personally spending quality time with each of you and
your staff in the field and very much appreciate that and your
commitment to our region and its people.
Ms. Blackburn asked of the previous panel a few question
about bricks and mortar, so let me tell you very briefly our
story in that regard. Immediately after Katrina destroyed our
buildings, we established limited clinic and urgent care
services in 10 hospitals, then in the Convention Center. We
operated a major clinic in a vacated department store right
next door to the Superdome, and in November 2006, just a few
months ago, we reopened part of our University Hospital. FEMA
indeed funded this renovation, provided the facility would be
operated only on a temporary basis. This small interim hospital
now operates 20 clinics which is in stark contrast to the 160
clinics that existed on the campus before Katrina. LSU plans to
open seven neighborhood clinics in the area as soon as permits
are finally granted by the city.
With the destruction of Charity Hospital, our flagship, the
region lost its only level one trauma center as noted by
Representative DeGette and other members. LSU then leased space
at a suburban Ochsner facility and began providing trauma
services there in April 2006. Trauma moved back to the interim
hospital just last month.
Also, LSU has indeed entered into formal collaboration with
the VA to build and operate a joint facility to permanently
replace public and VA hospitals. While this innovative project
will not be realized for a few years, the partnership and the
promise of a state-of-the-art academic health center does help
us resolve some of our short-term challenges, such as
attracting and retaining LSU and Tulane faculty and
researchers, not to mention the thousands of jobs and
significant value to the region's economy. And let me be clear.
LSU sees this project, this VA collaborative, as a meaningful
step toward health reform, not the same old Charity model. We
more than everyone want to get away from the so-called two-
tiered financing of health care.
And pre-Katrina, 70 percent of the practicing doctors in
Louisiana completed all or part of their training at Charity
and University Hospitals. But our educational programs are in
grave jeopardy as noted by Mr. Whitfield. We lost our radiology
and surgery program and most of our orthopedic surgeons. We no
longer have trainees in oncology or rheumatology. Other key
programs are still relocated far out of town. Surgeons are
under increased strain because of the manpower shortages and
enormous trauma demands.
Just a word about reimbursement. Public hospitals rely
heavily on the Medicaid DSH program in Louisiana and across
this Nation. Unfortunately, CMS considers costs associated with
payment of non-faculty positions to be unallowable under DSH.
They are not regarded as hospital costs. We have been working
to address this rule since 1999, and now would be an ideal time
to address it.
Another Medicaid financing issue is CMS's proposed Medicaid
regulation that will cut billions from the program. We simply
are in no position to absorb these additional cost cuts.
Mental health. There has been a significant loss of
capacity in the mental health system as a result of Katrina.
Only about 40 of the 400 lost psych beds have been restored in
the area so far. There has indeed been an exponential increase
in mental illness. ER's are under strain because of the volume
of the patients whose conditions require special facilities and
expertise not currently available. ER's weren't designed to
accommodate the needs of these patients and certainly not in
the volume we see today. According to press reports, police
often are unable to find a hospital able and willing to accept
mentally ill citizens. They are booking many of them in jail.
Emergency room overcrowding existed prior to Katrina but
has been significantly exacerbated since then. Several
panelists have already noted that. One way to alleviate the
situation is implementation of the medical home clinic concept
promoted by the State and its health care Collaborative
referenced by the chairman in his comments as well as other
panelists before me. This medical home will be the Holy Grail
of recovery and reform for it will address issues such as
electronic record interoperability that Dr. Verges noted in his
remarks.
And then lastly, workforce. There has been a mass exodus of
physicians and other medical personnel from New Orleans. They
are in huge and gravely short supply. As you know, members, our
challenges are great. We must overcome political in-fighting
and self-interest so that the interests of the patients are not
lost. Our task is to finally level the playing field of the
entire health care community to arrive at solutions that
transcend parochialism on behalf of the patient. As noted in my
written testimony, we cannot accomplish our mission without
additional Federal assistance in the form of increased funding
and regulatory changes, not just for recovery but for reform.
It is my hope that the attention this subcommittee can help
facilitate a productive dialog and produce positive changes for
the citizens of our region.
Thank you so much.
[The prepared statement of Mr. Smithburg appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you, Mr. Smithburg. Mr. Hirsch, please,
for 5 minutes.
STATEMENT OF LESLIE D. HIRSCH, PRESIDENT/CEO, TOURO INFIRMARY
Mr. Hirsch. Thank you, sir. Chairman Stupak, Ranking Member
Whitfield, and members of the subcommittee, thank you for
inviting me to testify today and for continuing to keep New
Orleans and post-Katrina health care a national priority.
I am here today to speak about a number of issues that
continue to plague Touro and other hospitals in New Orleans. I
am the president and CEO of Touro Infirmary. Thank you for your
support of New Orleans in the 18 months since Katrina
devastated our city. We are grateful for your continued
interest.
The delivery of health care in New Orleans today is a much
greater challenge than it was in the first few months following
the storm. Conditions have worsened and continue to do so as
more individuals return to New Orleans and as the demands on
the health care system increase. Health care is a core
requirement of the city's recovery, and the current system is
in jeopardy. Additional Federal support is desperately needed
to help stabilize and improve the situation.
Touro Infirmary was founded 154 years ago and is a faith-
based community, not-for-profit organization. It wasn't until
Hurricane Katrina struck that Touro would confront its greatest
challenge ever. For only the second time in its history, Touro
Infirmary closed on September 1, 2005, as we were forced to
evacuate 238 patients as well as hundreds of staff and family
members. We are very proud to be the first hospital to reopen
in the city just 27 days later and to be a critical part of New
Orleans' recovery, along with our colleague institutions that
have also shouldered a great burden.
Touro's reopening was critical to the city being
repopulated, and since then we have played a safety-net
provider role; and this has occurred at a huge financial cost.
Katrina caused over $60 million in property damage and business
interruption losses. We have had substantial operating deficits
since the storm, and the Touro Governing Board recently
approved the deficit budget for 2007. We continue to erode our
cash reserves at a rapid pace and endure the impact of
resulting changes in our bond and credit ratings.
The situation as you have heard today in Orleans Parish is
particularly challenging as the number of acute beds in
operation remains dangerously low at about 500 to serve a
population estimated at 200,000.
With 2,000 employees, Touro is presently staffed for 280
beds. There are a significant number of issues that have had a
negative impact on the operation of hospitals in the New
Orleans metro area and the health care delivery system. The
amount of uncompensated care provided by area hospitals and in
the increased percentage of population that is uninsured is
unprecedented and exceeds national levels. There is also a
significant portion of the population that is underinsured.
Touro's charges for uncompensated care have skyrocketed
from $17 million pre-Katrina to $41 million in 2006, an
increase of 141 percent. Our emergency department has seen a
dramatic increase in volume post-Katrina from approximately
20,000 visits a year to 30,000. Uninsured patients originating
in Touro's emergency department are responsible for about 90
percent of Touro's uncompensated care. This is an unsustainable
position for Touro and is an unfunded mandate that we willingly
accept but must be addressed in terms of the financial
viability of our hospital.
There has been a steep rise in the cost of labor, excessive
reliance on contract labor, and shortages of critical health
care personnel to fill both direct care and support positions.
The national nursing shortages exacerbated in post-Katrina New
Orleans, and salary rates have risen significantly. The use of
contract or agency labor particularly with respect to
registered nurses is a large component of the labor shortage
issue. At Touro, the cost for each man-hour paid increased 20.4
percent from 2005 to 2006 driven largely by the cost of
temporary labor which increased nearly 500 percent. Annually,
the cost of a full-time equivalent registered nurse provided
via a staffing agency is $50,000 higher than the cost for a
similar nurse with salary and benefits employed by the
hospital. 17 percent of our labor costs last year was for
contract labor and amounted to nearly $14 million.
Graduate medical education. Post-Katrina Touro and other
hospitals expanded their residency training programs to absorb
as many residents as possible, thereby supporting and
protecting the future of graduate medical education in New
Orleans. We increased from 18 to 52, however because of this it
has been very costly in that the Federal rule does not permit
Federal full reimbursement in the first year. Instead, costs
must be averaged over a 3-year period; and in effect, we are
being penalized. This rule did not envision the hardship
created by Katrina. Our incremental costs associated with this
for the 3 years of the averaging will be $9 million, and of
this amount, $4.5 million is related to the 3-year averaging
requirement.
Property and casualty has also skyrocketed. We are up 374
percent. At the same time, our coverage has declined. We have
taken a number of steps to help ourselves, but yet some of
these measures have not been seen fit to be funded by FEMA
which I could elaborate on in greater detail.
Our recommendations are simply to implement health care
redesign that provides participants with freedom of choice to
obtain health care services and assures that funding follows
the patient and is not institution specific. Approve cost-based
reimbursement for the next 3 years for hospitals in hurricane-
affected parishes, and particularly, for hospitals located in
the hardest-hit area, region 1. Treat our hospitals as critical
access hospitals similar to what has been done for rural
institutions or those institutions in rural areas.
As noted before, approve a Medicare wage index now that
reflects the current conditions and don't wait 3 years for the
rates to catch up. Increase funding for uncompensated care and
consider special grants for those hospitals most affected.
Approve waivers for graduate medical education so the problem
that I described before will not affect those institutions that
stepped up, and also approve additional family practice
residency training slots to increase the supply of primary care
physicians and waive the administrative barriers that are in
front of adding those programs.
Increase access to physical rehabilitation services.
Physical rehab service particularly for brain injury patients
are in short supply; and at no cost to Medicare, rehab
hospitals could be permitted to change status to become
rehabilitation units of general hospitals without the current
1-year reduced payment penalty. Approve additional funding to
increase health manpower and revise existing programs to
incentivize physicians and others, nurses, et cetera, to come
to New Orleans for perhaps a 3-year period with grant support.
Designate us an underserved area for this purpose, and provide
hospitals with direct funding to provide similar incentives.
Deploy Federal resources to help relieve pressure on
emergency rooms in the area. DMAT teams were very useful after
the storm but left well before the population returned. DMAT's
should be reconsidered and redeployed to help alleviate the
excessive delays in treatment and overcrowding that currently
exists in hospital emergency rooms. Finally, please consider
additional funding to offset the cost increases in property and
casualty insurance that I noted before.
I thank you again for the opportunity to be here.
[The prepared statement of Mr. Hirsch appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you and thank you to all the witnesses
for being here. We will start with the questioning, 10 minutes
for each.
You know, you all put in countless hours and energy and
your talent to try to solve the health care problems that New
Orleans faces, especially in region 1. And yet the health care
system, as we have seen today, seems to be deteriorating and
not getting much better.
I asked the other panel, but let me ask this a little
differently because of the makeup of this panel. Give me one
thing that is breaking down in the Government and the private
or public sector's ability to solve some of your challenges.
Mr. Hirsch concluded with his. I talked with him about DMAT. I
don't know if that is something we should do right now or
anything we could do right now to help alleviate the problems;
but Dr. Miller, let us start with you and we will go right down
the line and give Mr. Hirsch a chance to think about that one.
What could we do? Give me one thing we could do right now that
you need the Government to put some pressure on--besides the
dollar part. We understand dollars.
Dr. Miller. Certainly one of the greatest challenges for us
as a training institution which will affect the current and
future supply of physicians is the difficulties related to our
graduated medical education programs, being able to move
residents from the hospital where they trained prior to that
hospital going down to new locations; and as Mr. Hirsch pointed
out, those new locations getting adequately paid for those
residents so that they can reimburse the medical schools. And
we are all under very careful scrutiny by our accrediting
agencies, and we have to make sure that the quality of the
educational experience and the interaction between medicine,
surgery, pathology, all of those trainings are intact.
So certainly we need flexibility within CMS and we need a
clear understanding of what the criteria are for acceptable
training sites.
Mr. Stupak. Mr. Muller?
Mr. Muller. Access to nurses. We simply could open more
beds if we had more nurses. Every hospital in town could open
more beds if they had more nurses.
Mr. Stupak. You have the physical space?
Mr. Muller. Oh, absolutely. We have the physical space. We
have the support staff basically. But the nurses are not there.
We cannot go on paying agency nurses because they cost like we
have been told twice as much.
Mr. Stupak. What is the barrier? Just no nurses in the
area? Is that just it?
Mr. Muller. Yes. Well, there are many barriers but the main
one, there are no nurses in the area.
Mr. Stupak. And that is housing or----
Mr. Muller. People really don't want to move back for
various reasons, schools, levees, housing, other things. In
fact, when you compare living and working in New Orleans to
living and working in Austin, TX, Ann Arbor, MI, there is no
choice for quality of life at this point. It is really nice to
come to a city where the streets are clean and thing are going
on like it is in Washington. You cannot attract nurses to come
back to an environment like this.
Now, another answer, though, is we received volunteer
Veterans Administration nurses at West Jefferson for about 6
months. They were wonderful. They enjoyed doing it, they had
jobs. I think something needs to be done I believe at that
level that will cost less. We cannot hire agency nurses
forever.
Mr. Stupak. OK. Mr. Quinlan?
Dr. Quinlan. It lapses a little bit into the financial
piece, but I think if we could make reimbursement reflect
current costs, I think some of that is by design that makes
sense in ordinary circumstances. But if we could review some of
these administrative rules to recognize that this is an
unprecedented situation and it should reflect current reality,
I think it would put us on a different footing because
sustainability is how you make your plans going forward, and in
the absence of predictable revenue stream, you have to think
differently.
Mr. Stupak. Give me a specific on your reimbursement you
are talking about, such as critical access hospitals?
Dr. Quinlan. Well, that would be huge if we could do that,
but I remember about in the first week saying, if we could have
a critical access designation, this would be tremendous for us.
Mr. Stupak. And how long would that have to stay for? There
is always a concern that once you do it, it never goes back.
Dr. Quinlan. Pick a number.
Mr. Stupak. A year? Two years?
Dr. Quinlan. We can live with anything to tell you the
truth. It is taking I think a year-to-year or a biannual sort
of thing where you would judge it against certain criteria. It
would allow us to have that sort of wherewithal to deal with
this.
Mr. Stupak. Mr. Smithburg?
Mr. Smithburg. First I agree with the comments made by my
colleague panelists. I am going to add another one. Everything,
Mr. Chairman, seems to touch money in one way or another.
FEMA has already been budgeted, and as I appreciate
appropriated and authorized dollars. And so in the case of the
publics, it is a matter of dislodging funding to fit within the
FEMA center lane. And in the case of the mental health crisis,
while we have tried to find several facilities to lease, at the
end of the day we have finally landed on one that will work so
that we can stand up a mental health hospital to support the
community, but it requires FEMA's approval and that is an issue
that we continue to have trouble getting across.
Mr. Stupak. FEMA approval for what, for allow more cost
or----
Mr. Smithburg. No, FEMA approval to replace that which was
destroyed by Katrina in the form of mental health beds. And we
have a beat on leasing a facility that requires renovation that
should be eligible by FEMA. And I think that would help the
community greatly.
Mr. Stupak. OK. Has FEMA resolved your money yet for Old
Charity? The last time we had a hearing that was a big point of
contention, and they were going to do it right away they told
us. So what ever happened there?
Mr. Smithburg. It is still being evaluated, Mr. Chairman.
They did bring in another team, the fourth different evaluation
team is now in to Big Charity to adjudicate that claim if you
will. But FEMA has helped us get into University Hospital as a
temporary facility.
Mr. Stupak. What is the dollar difference we are at yet?
Mr. Smithburg. I don't know. The last official dollar
difference is the same place we were before which was $225
million. But I think they have a new group in there that is
looking at it a little more objectively.
Mr. Stupak. OK. Mr. Hirsch?
Mr. Hirsch. A couple of ideas. It was mentioned earlier
about the frustrations in New Orleans and Louisiana among the
different groups, the State, the Federal Government, as well as
of other interested parties. And I don't know to the degree
that this is practical or realistic, but to the degree that
Congress or someone can play a role in mediating or trying to
arbitrate the situation so to speak. There are a lot of people
working with a lot of good intentions, in some cases, frankly,
at cross-purposes; and people need to get together and have
what I would call a real conversation and try to reach a middle
ground and compromise. That has been a big part of the problem.
I don't think that the parties are all speaking with each
other.
Mr. Stupak. Mr. Dingell has asked the Secretaries of HHS,
FEMA, some of the others, to sit down as a group. Would you be
supportive of that?
Mr. Hirsch. Absolutely, as well as all representatives or
representative constituencies of the industry, the private----
Mr. Stupak. Well, that is why our first panel was so big. I
know I was harassed a little bit because of the size of the
panel. But we didn't feel like we could exclude anybody because
you all have a stake in it. We want to get you together and get
you talking.
Mr. Hirsch. And I think that would be wonderful and that
is--I think that situation is what is going on there and that
is a big roadblock is if the parties aren't speaking.
The other thing, some of the comments that were made
earlier about the requirements of DSH, some of those
requirements preclude for instance, say, Don's organization and
us at Touro, we at Touro, from potentially contracting for
services and not having to have patients go 60 miles, not
having backlogs as well. So that is something that I think is
real. It ought to be considered.
And finally, one of the recommendations that I noted in
terms of access to physical rehabilitation services. We think
that is an easy lift. We are a hospital within a hospital now,
and if we could convert without a 1-year penalty, we believe we
could get certain economies and increase access. So that is
something that we are working on.
Mr. Stupak. Let me ask this question. We have talked a lot
about dollars following the patient, and that has been
throughout both sides of this dais today talking about it.
However, the fear that sort of comes out is as the dollars
follow the patient, the private hospitals if you will, will
only take the healthiest patient and the less healthy, those
with HIV's, the prisoner patient, would be left then to the
public. And as we try to work this out, it is not just this
committee, but 435 of us in the House of Representatives alone,
it is a hard built-in bias, whatever you want to call it, to
break. People are afraid that if we do that, some people will
skim off the healthiest patients and leave the poorest. Care to
comment on that, Mr. Muller?
Mr. Muller. We are taking them right now and would be glad
to.
Mr. Stupak. That is what we are hearing from your lost
revenue and things like that.
Mr. Muller. That is correct. We are a public hospital. Our
mission is to take care of people. We have patients lined up
every day to come to West Jefferson. We have a continuum of
care. If the money followed the patient, it is a win-win. It is
not a problem with us.
Mr. Stupak. And your comment, Mr. Quinlan?
Dr. Quinlan. Yes, I would just reiterate the same thing. We
are already doing this, and I think what we really need to do
is allow people to vote with their feet and I think it is very
important that they do that. It helps us all keep better--there
is a degree of competition that is healthy, and I would say
that is true in any walk of life, including medicine, and trust
the common sense of patients to take care of themselves best.
I would like to add one thing. Taking care of this primary
care network is probably the most important thing you can do to
take care of hospitals because let people do what each does
best and no more than that.
Mr. Stupak. Mr. Smithburg, you want to comment on that?
Mr. Smithburg. Well, there is no doubt that the not-for-
profit, faith-based and private institutions are carrying their
heavy loads since the storm. There is no doubt about that. And
after the storm, we lost all of our employees, and our budget
was cut by about $200 million. A good amount of that was
actually redeployed to help support my colleague--institutions
and caring for those patents that would have otherwise been
cared for in our institution. You see, New Orleans has a
tradition whereby between 90 and 95 percent of the uninsured
got their care at the Charity Hospital, and the balance of the
uninsured, the remaining five to 10 percent, was spread around
all of the other community facilities. Katrina turned that
upside down. And I don't know that she leveled the playing
field but she certainly changed the playbook.
And so to the extent that rules, regulations can be
addressed to allow for what heretofore were non-allowable costs
to be allowable, at least for an interim period of time, I
think that helps the entire environment.
Mr. Stupak. Thank you. Thank you again to the entire panel.
Mr. Whitfield, for 10 minutes, please?
Mr. Whitfield. Thank you, Mr. Chairman. Thank you all for
taking time to come and be with us today. As I was listening to
your testimony, I know Dr. Quinlan, you made the comment that
we can't do this much longer and we are committed until the
end. I think, Mr. Hirsch, you talked about operating deficit
and eroding cash reserves; and I am assuming that all of you
representing the institutions you represent are in that same
boat. Am I accurate in that? I mean, are the eroding cash
reserves in a deficit situation and your emergency rooms are
being overrun; and that is why I know in the first panel so
much emphasis was being placed on this primary care or getting
that going which would be of some assistance to you. But Dr.
Quinlan, if things continue to go the way they are going now,
how much longer can you operate?
Dr. Quinlan. That is a good question. What we have done is,
unlike trying to make a statement, we realize that we are just
not going to put the patients in the middle. We are approaching
the point where we will have to restrict our policies because
if we go under, we can't help anybody. And due to the size of
our organization, the impact of that failure would be huge and
the impact would be felt by our colleague institutions
throughout.
The difficulty is that it is all related. I think the key
to us would be that as we cut back, what we would have to do is
probably not keep up with wages and benefits; and this vicious
cycle we are in in losing personnel would be accelerated. And
when that starts to happen, that is what we are afraid of. You
know, cycles, you are either getting better or you are getting
worse. And I feel we are sort of hovering right now.
Mr. Whitfield. Yes. And do all of you face significant
unemployment claims that you are liable for?
Mr. Hirsch. Yes.
Mr. Whitfield. OK. And you, Dr. Miller?
Dr. Miller. I am just not aware because a University is in
a different situation than a hospital.
Dr. Quinlan. Well, to your point, as I understand it, there
was significant relief from Congress for unemployment relief,
but it did not apply to not-for-profits.
Mr. Whitfield. Oh, it did not apply?
Dr. Quinlan. It did not apply for not-for-profits. And in
our case it is particularly irritating because the unemployment
claim we feel was unfounded in the first place. So we didn't
get the relief but we got the bill. That is a tough one to
take.
Mr. Whitfield. Right. Chairman Stupak and I were talking
during your testimony about the critical access hospital
designation which means you are reimbursed at cost plus. That
would be a tremendous help to all of you making it happen
immediately, correct?
Dr. Miller. Yes, sir.
Mr. Whitfield. That would really be a significant help,
wouldn't it?
Dr. Miller. I just think one thing--and certainly not to
minimize the issues of the hospitals because that is very
critical. We can't forget the physicians in the equation.
To every extent, we all represent physicians as part of
our organizations, but as little as it has been, there has been
some relief for the hospital but there has really been no
relief for the physicians. So a patient is admitted through the
emergency room and there is a potential for the hospital to
gain some reimbursement for it. But that patient has to be seen
by a physician or perhaps several physicians, and they are not
getting reimbursed for it. And the threat there is that we lose
more physicians. It has been stated earlier today that we are
down to about 50 percent of our pre-Katrina physicians in
region 1. It is significantly more severe than that in Orleans
Parish; and I am sure as you know in St. Bernard, it is even
more so. And unless we fix the physician situation while we fix
the hospital situation, we will wind up with wonderful
hospitals and no doctors to take care of the patients.
Dr. Quinlan. I would concur with that, but I would add that
with our new hospitals that we have acquired that were in
trouble, when physicians come in--these are voluntary staff--
come in to see patients, we pay them Medicare rates because we
are trying to do everything we can to keep them afloat.
If you do work, you need to get paid. I think that is not a
bad policy in general for the Government to observe.
Mr. Whitfield. Mr. Muller.
Mr. Muller. Yes. If I could, we feel the same way about
physicians. We have actually gained physicians at West
Jefferson, most from St. Bernard, some from Orleans Parish
because we ended up being dry.
But we have done a couple things, one is to share what we
could back to the physicians in terms of what we could legally
to keep their offices open, like Dr. Bertucci is trying to do.
Second, we are paying them for uncompensated care now in the
emergency room; but that is coming out of the hospital's budget
which makes our deficit worse. So additional money for
physicians is good.
Mr. Whitfield. Part of the responsibility of this
subcommittee is to come up with proposals, and I know that we
have a gentleman from Louisiana on the committee now who is
certainly focused on this issue. And I hope that as a result of
this hearing we can come forth with four or five proposals like
critical access hospital and something related to community
health centers and other things to try to expedite something
through.
And many of you were talking about the nursing situation,
the shortage of nursing; and yet Mr. Koehl I believe talked
about that in Louisiana, the State had made a decision that
they would not allow nurses to come in from outside this State
unless they were licensed. Help me with this. Is that right or
did you hear his comment or did you know anything about that.
Dr. Quinlan. I heard his comment. I am not familiar with
the issue.
Mr. Whitfield. Well, maybe the next panel could address
that because it does seem a little bit odd that with such a
shortage that the State would, at least from the testimony from
that witness, be an obstacle to bringing more nurses in.
And then another thing that concerns me I think in
someone's testimony and I forgot who, it mentioned in the
testimony that on 9/11, 2001, that the Federal Government
stepped in immediately and provided some immediate assistance
to hospitals in the New York area as well as the Washington, DC
area. And would anyone want to elaborate about that? Mr.
Muller.
Mr. Muller. I would be glad to. We received a DMAT 12 days
after the storm. The DMAT went from positioned in Tennessee,
State of Mississippi, didn't do anything, went back to Baton
Rouge, didn't do anything, and we got it and we were the first
DMAT. Now, there is more that the Government could have done. I
don't want to go back, but some of the things going forward
could be more grants for health care personnel.
Dr. Quinlan. I think perhaps you are alluding to the HRSA
grants that after 9/11 hospitals closed--largely took people
out in anticipation of a wave of casualties that didn't occur.
That sort of thing would be great for us and would also be
important for the future where--how else can the Federal
Government get funds to hospitals? They need to keep them
afloat virtually.
That is the kind of thing that would help because I have
run into so many people who would like to help but were unable
to for a host of reasons that you know all too well, and the
HRSA grant possibility is giving the kind of flexibility to
assess what the need is and meet it in a timely fashion.
Mr. Whitfield. Yes, because I mean, the key thing now is
being able to be flexible.
Dr. Quinlan. That is right.
Mr. Whitfield. And one of the frustrating things is health
care is so complex that it seems like every time you try to do
anything, your hands are tied or it is this regulation or that
regulation. It is micromanaged so it is very frustrating. And
then our staff had looked up on the DRA money for example, and
I am not being critical of the State of Louisiana because with
the catastrophe the size of the catastrophe, but it is my
understanding DRA money that the State of Louisiana has is $140
million left still unspent, SSBG money $142 million left
unspent, DSH money currently $250 million unspent. I won't even
get into the uncompensated care poor or the CDBG monies.
So hopefully this hearing will focus on some of these
things, and we can come forth with some sort of legislative
proposal to help move it along. But thank you all very much for
being here. Listening to everyone you can see why the
depression rate is up in Louisiana because it is so
frustrating. Thank you very much.
Mr. Stupak. Ms. DeGette for 10 minutes.
Ms. DeGette. Thank you, Mr. Chairman. I want to follow up
on some of the questions that the chairman was asking. We have
been talking about this notion of having some of the State's
DSH money reprogrammed to follow the patients, and I have got
to say for the gentlemen who are here from the private
hospitals, and I say this a lot but I will say publicly again,
thank you, because your hospitals treated so many of these
patients and are continuing to do so now with minimal
reimbursements. And it really has been an extraordinary
community effort.
Dr. Quinlan, I have been in your hospital and seen some of
the work that you are doing. I am wondering if the three of you
gentlemen, Dr. Miller, Mr. Muller, and Dr. Quinlan, can tell me
about what would need to be done to reprogram the State's DSH
monies to follow these patients and what rules would we need to
change at the State and Federal levels. Dr. Miller?
Dr. Miller. Well, again, currently the way that the State
DSH dollars are used, they basically are centered around
patient care that has been delivered in the safety-net hospital
system with a small amount going to other hospitals that
provide significant amounts.
Ms. DeGette. Believe you me, I know how DSH works. What I
am asking you is what Federal rules and State rules would need
to be changed to reprogram these dollars?
Dr. Miller. Again, I am going to let the hospital CEOs talk
for the hospitals, and I will talk for the physicians because
again, we have a group of 200 physicians at Tulane University.
And the rules need to be changed to allow DSH payments go
directly to health care providers other than facilities, and
that may be physicians, nurse practitioners, and other health
care providers.
Ms. DeGette. How long a period would you think that that
reprogramming would need to occur?
Dr. Miller. Well, it certainly needs to occur until we have
a stable health care system back up in the region and decisions
are made about what we are going to have in terms of a safety-
net hospital, how big it is going to be, and when it is going
to be available. And so that during the period of time when we
are between where we are now and where we are going, there
needs to be some type of alternative system.
Ms. DeGette. Two to 3 years is what they have been saying
to me.
Dr. Miller. And again, that will depend on how quickly we
can get the system stabilized.
Ms. DeGette. Mr. Muller, would you have anything to add?
Mr. Muller. Absolutely. There is a lot of money. The DSH
money in Louisiana is large. The reason we are saying let it
follow the patient is because it is there now.
Ms. DeGette. You know, again, I understand. What specific
regulations would we need to change?
Mr. Muller. My testimony had actually two things, one is
the Medicaid proposed rule that would allow the funds that were
certified by--now, the certification is done by the public
hospitals. And so the certified funds are matched with Federal
funds that come in. We are asking the Federal rule to come
directly to the provider. Don't go to the State. That is
already a proposed rule.
The other thing is a certification of the public
expenditures, needs to be something that comes back directly to
the provider; and then we can deal with the physician. I think
if we get a lot of that money, which in our case would be
multi-millions, we would share more of the physicians.
Ms. DeGette. And I will ask you the same question I asked
Dr. Miller. For what period of time do you think that funding
arrangement should occur, that the DSH money should go directly
to the hospitals and then onto the providers?
Mr. Muller. I support having a major teaching hospital in
New Orleans. It will take 6 to eight 8 to have that come up.
You got others that will tell you other dates but----
Ms. DeGette. So you are saying the same thing he does as
long--for the period until that public safety-net hospital gets
built, you think that that should happen?
Mr. Muller. Until we have a fully functioning safety-net
system outside of my hospital and Dr. Quinlan's and others, we
should have those funds come directly to our hospitals.
Ms. DeGette. And for that period of time, would your
hospital commit to serving all of the safety-net patients
including the ones Mr. Stupak was talking about like the
severely mentally ill and people with a plethora of conditions
and so on?
Mr. Muller. West Jefferson has a continuum of care. We are
doing it today, we will do it until we run out of money.
Ms. DeGette. Dr. Quinlan?
Dr. Quinlan. With regard to the proposed changes, what I
would like to do is give you a written response so it could be
most helpful.
Ms. DeGette. That would be excellent. Thank you.
Dr. Quinlan. Yes. The second piece on the timing, it should
be an event-based decision, not a calendar-based decision.
Decide what things need to be dealt with and then if there are
certain benchmarks or milestones that need to be reached----
Ms. DeGette. But what event would you base the decision on?
Dr. Quinlan. I think the health care we designed--I have
been involved with this committee since its inception, and that
I think that is an important piece to determine what is the
best way to do this in an ongoing fashion, rather than trying
to look backward, how do we look forward and meet the needs of
patients. And that is----
Ms. DeGette. What event is that, I am sorry?
Dr. Quinlan. Excuse me?
Ms. DeGette. What event would you base--you said it needs
to be an even-based decision.
Dr. Quinlan. OK. Well, the event for example would be do we
have a written plan that is acceptable for all the major
stakeholders how we are going to deal with health care in the
next year or two.
Ms. DeGette. Would that include LSU?
Dr. Quinlan. Of course.
Ms. DeGette. OK. And do you support the concept of the
rebuilding of a major safety-net hospital?
Dr. Quinlan. Yes, I do.
Ms. DeGette. Mr. Smithburg, I want to ask you, from your
perspective, do you think a temporary reprogramming of DSH
monies can be developed in a way that won't prevent LSU from
building a public hospital in downtown New Orleans?
Mr. Smithburg. You know, you used the term, let the dollar
follow the patient.
Ms. DeGette. It was actually Dr. Quinlan's term that I
adopted.
Mr. Smithburg. Indeed. Thank you for the clarification. It
is a much bandied-about term in Louisiana and I know in other
States as well. I think what has evolved is that through the
Collaborative that some of us served on, the Governor's
Collaborative on Health Care Redesign, it tried to actually
define what that is because one of the fears, of course, is
that what happens to the patient when the dollar isn't
following them?
Do they fall back on a safety-net system that has
historically in the New Orleans region also been one of the
primary academic flagship institutions? And so the
collaborative that we worked on collaboratively came up with a
plan that said, there just isn't enough DSH money for, based on
actuarial studies, for there to be enough money to follow all
of the uninsured patients in the market. In fact, it would cost
another half-a-billion dollars conservatively estimated. And
then of course, Secretary Leavitt came through the State and
proposed another plan after he and Governor Blanco had
commissioned the Collaborative; and it called for an insurance
plan that did away with the safety-net hospitals, use those
funds to insure about 40 percent of the uninsured. So it was
kind of a perfect storm as far as we were concerned in the
public teaching hospital arena.
So at the end of the day, clearly, Representative DeGette,
something needs to be done to protect the business plans of the
community hospitals that are doing an outstanding job. But I
fear that if it is a 3-year window or a 5-year window, when we
get our permanent LSU VA Tulane hospital up and running in 5 to
7 years, whatever it is, if then we say, OK, they are the
safety net, they are going to go back to taking care of 95
percent of the uninsured as was the case pre-Katrina, we are
right back to the two-tiered funding system again and we will
not have advanced the ball in terms of health care reform and
perhaps quality and the like.
So I think it is a dangerous proposition to enter into,
without some very tight accountability expectations and with an
expectation that we are still working toward a real reform of
the system, not your grandmother's Charity Hospital system
again.
Ms. DeGette. I agree with that and I think these things can
be worked out because on the one hand, I think everyone agrees
we need to--and Mr. Chairman, maybe this is why we brought
everybody here together because I think everybody agrees we
need to reimburse the private hospitals who have been treating
these patients. On the other hand, I think everybody, including
the private hospitals agrees we need to rebuild Charity and not
in the same footprint. The very concept of disproportionate
share hospital, which is actually an issue Mr. Whitfield and I
have worked on extensively together, is a hospital that treats
a disproportionate share of uninsured patients. So that
wouldn't qualify for, except for maybe lately, some of the
private hospitals. So the very concept of these monies would be
that it would go to a public safety-net hospital. So whether
the way we reimburse the private hospitals is through DSH or
some other method and the way we think about Charity going down
the road is not through a two-tier system. We have still got to
work this thing out, and I would think we should be able to.
So I appreciate all of you working on it, and I neglected
to say hello to my old friend Mr. Hirsch who used to work at
St. Joseph's Hospital in Denver, Colorado.
Mr. Hirsch. Thank you.
Ms. DeGette. So anyway, I think this can be done, and I
think a lot of what is trying to be done by Congress and by the
providers and the local governments is trying to figure out a
reimbursement method that fits. It is sort of a square peg into
a round hole or vice versa, a scenario where you are trying to
think of these pots of money and how can you get them. But I
don't think anybody, and Dr. Quinlan and the others can correct
me if I am wrong, I don't see DSH money as a long-term solution
to how we treat these uninsured patients.
Dr. Quinlan. No, and I think what you are saying is exactly
correct. We have to make sure that this is a comprehensive
plan, not reactionary or piecemeal because each one of these
major factors affects the others. This is a variable equation
with no constants. We have got to get something that we can
build from and have a plan that is sustainable, and I don't
think it is just about DSH money and it is not just about
primary care, it is about how do we weave together a health
care system that is coherent?
Ms. DeGette. And that health care system has to include an
up-to-date public safety-net teaching hospital and a clinical
system with all of the things we have talked about, electronic
records----
Dr. Quinlan. But the order in which you do that is very
important. I don't believe we start out with a hospital and
then figure out the primary care network that supports it and
all the things that go with that. I think it is how do we
decide what our goals are, what caliber of education do we want
in that region, what caliber of care do we want for patients.
Is it going to be something they can walk to, bus to, or
bicycle to, and will they be connected in a way that you can
actually manage the health of the population as opposed to
individuals on a sporadic basis? And we need to spend the time
to do it right up front, rather than rushing to just do
something on a very large scale. Now, I do think the short-term
needs are immediate and really need to be dealt with; but that
is not a substitute for a planned-for approach to a
comprehensive solution.
Ms. DeGette. I agree. On the other hand, it has been 18
months, and so we need to start to come up with that plan
pretty darned quick.
Mr. Hirsch. May I just add that I think it is important to
remember that some of this also depends on the socioeconomics
of an area, specific locations. We have a lot of people in our
area that are underinsured as opposed to other parts of the
country. And take Touro, for instance. We are right in the
heart of the city, so we are an urban center; and people will
vote with their feet. And so we have to I think keep in mind
that even before the storm as well as after the storm certainly
that much worse, all these private hospitals and some more than
others have been providing a lot of free care; and I think it
is important to think about DSH or some other mechanism well
into the future, and I certainly support the rebuilding of an
academic medical center. I look at it that way as opposed to
just a safety net because the health sciences are so important
to our city. But I think for a long time to come, hospitals in
urban areas, especially New Orleans, will be affected by the
uninsured some more disproportionately than others.
Mr. Melancon [presiding]. Thank you, Ms. DeGette. I think
Dr. Burgess is next up for 10 minutes.
Mr. Burgess. I thank you and let me just start out with
this observation. In October 2005, I did visit New Orleans as a
guest of East Jefferson and West Jefferson Hospitals, Ochsner
Hospital. They asked me to come down there because they had a
plan that they had worked out with their medical staffs to stay
open, keep their bondholders happy in New York, and it hinged
around shaking some money loose from the Federal Government.
And the hospitals were going to function as the intermediary
through which that money flowed, not only to keep the hospitals
open, keep the nursing staff employed, but also to reimburse
the physicians for the patients that they were seeing. At this
point, when I talked to doctors down there, they had not had
any mailed delivered in 2 months' time, their accounts
receivable were a shambles, and they were basically living off
of their kids' college funds in order to keep their practices
open. I thought it was a very insightful, responsible way to
deal with a crisis the likes of which none of us had ever seen
before. And it is with some pain that I acknowledge we were
never able to deliver what seemed to be a very reasonable
request by the hospitals that stayed open through the storm and
were still standing after all of the trouble that occurred in
the days after the storm.
So let us go back for just a moment to the DSH funds. My
understanding is there is about a billion dollars a year in
disproportionate share hospital funds for the Louisiana area?
Now, the $250 million that we always talk about, is that the
money that was from the last quarter of 2005 that wasn't spent
because Charity no loner existed and is there an ongoing stream
of DSH funds that are coming through the State for
administration of care for insured individuals and underinsured
individuals?
Mr. Smithburg. Dr. Burgess, I will take a crack at that,
but that may be a good question to ask of State officials on
the next panel as well.
But of the billion dollars roughly speaking about $600
million of that goes to the public hospital system, the State
public hospital system, or it did before the storm. Right now
it is about $450 million. And then a good chunk of it goes to
the State psychiatric facilities and for rural hospitals. The
breakdown could be provided by the State officials, however.
Mr. Burgess. So those dollars are now distributed to other
State facilities outside of New Orleans?
Mr. Smithburg. In the case of the LSU public hospitals,
again we had a pretty significant reduction in our DSH dollars
after the storm and then some that we previously had in New
Orleans that remain, we redeployed to some of our other
hospitals that picked up the slack in Baton Rouge, Lafayette,
Home Louisiana, and then outright cut.
Mr. Burgess. I don't now whether you noticed but it is a
recurring theme with me that I am just astounded by the amount
of dollars that have been pumped into a problem and again, we
don't seem to have helped anyone on the ground. You know, I
haven't been in public service that long, but it is enormously
frustrating to me. I get criticized at home because we are
spending so much money on this, and then at the same time, we
have not helped anyone in the process. So I do wonder what
happens to $100 billion in appropriations that we sent down in
2005. I wonder what happens to $2 billion we sent to the DRA. I
wonder what happens to $2 billion a year that is available in
DSH funds. And at some point, I hope someone can give me some
type of spreadsheet that will give me some insight into that to
at least give me some comfort. Someone, and I don't remember
who, talked about some of the barriers for the critical access
hospitals, but that seemed to me when that discussion was going
on, very similar to the plan that was outlined by East
Jefferson, West Jefferson, Ochsner Hospitals in October 2005.
So I think it was actually Chairman Stupak who asked the
question, what can we do at this level to see that those funds
actually go into those critical access hospitals and are there
for immediate distribution? Does anyone have an insight into
that?
Dr. Quinlan. You will need to change the definition of
eligibility. They are size-limited. I think they can only have
25 inpatients. It depends on how you define critical access. It
was defined with a rural environment in mind.
Mr. Burgess. Well, perhaps we could denote a special
category for a special, once-in-a-lifetime catastrophe.
Dr. Quinlan. I agree with you. It is called flexibility,
and that is what has been absent in all this.
Mr. Burgess. Well, you are right on that.
Mr. Muller. Dr. Burgess, can I follow up and show you what
could be done? West Jefferson is about eight miles from a
critical access hospital. St. Charles Parish is right next to
Jefferson Parish on the west bank. St. Charles Parish has a
critical access hospital. West Jefferson is not, of course.
Mr. Burgess. Since you volunteered that information, Mr.
Muller, let me ask you a question about the nursing. You said
that you are spending a lot more money on agency nurses than
what you would spend on nurses who were salaried and on your
staff?
Mr. Muller. About twice as much, yes.
Mr. Burgess. Where does the agency get their nurses?
Mr. Muller. All over the world. They get them from
California, Michigan, and everywhere else; and they fly in, we
pay for them.
Mr. Burgess. The question that Mr. Whitfield brought up
about the licensure issue, is that something that concerns you?
Is that going to be a problem with the agency?
Mr. Muller. We have not had that issue with our agency
nurses, no.
Dr. Quinlan. I believe that was referring to volunteers.
Mr. Burgess. Just to volunteers? But if you have a nurse
from Dublin, Ireland, who is licensed to practice nursing in
Ireland----
Dr. Quinlan. That is a different story altogether. That is
a visa question which is something we could receive help on
certainly. We are planning on pouring a large number of nurses
from out of the country as well to meet this need, about 100,
and we have been shepherding this with the help of our
delegation actually, shepherding their immigration along. But
that is the sort of complexity we are--if we could address
that--because we are in the midst of a national shortage that
is just exacerbated by our particular situation.
Mr. Burgess. But even if you are able to steal nurses from
Detroit, Michigan, are you going to have the licensure issue
that comes up in a month's time?
Mr. Muller. No, I don't believe so.
Mr. Burgess. How does the agency get around that?
Mr. Muller. They work out the requirements with the State
Board of Nursing.
Mr. Burgess. So there is a reciprocity agreement?
Dr. Quinlan. They are travelers and these are people that
do this for a living basically, at least for a period in their
lives. So they have licenses at different States as well.
Mr. Burgess. One of the other issues that came up was that
we are not able to reimburse CRNA's and physicians under some
CMS rules, that those funds have to go directly to an
institution and not to a provider.
Dr. Quinlan. Right.
Mr. Burgess. Again, is there some flexibility that we can
provide you that we are not that would allow you to pay these
providers and keep them in the area?
Mr. Smithburg. Hi, Dr. Burgess. I will be one of those to
take a crack at that. In fact, when I was your constituent in
north Texas, I worked for a hospital system where CRNA costs
were indeed considered allowable by the fiscal intermediary
which is the same fiscal intermediary that oversees Louisiana
as well. So there seems to be some variability in
interpretation of those allowable rules in different regions of
the country.
So it is one of the reasons why I feel very strongly it is
something we need to pursue.
Mr. Burgess. So that must be a question for the third
panel.
Dr. Quinlan. We will get you a written response as well to
see if we can help you with your options.
Mr. Burgess. Very good. Dr. Quinlan, just in the time I
have left, you talked about a coalition for the uninsured, your
overall health care redesign and developing a plan for the
delivery of that health care. Can you kind of just give us some
insight as to where that is in the development process, who is
involved, and where it is going?
Dr. Quinlan. Yes, actually there are a number of players,
many of whom--it is a sort of a reconstitution of the previous
redesign plan that we just wanted to get back together and pose
an alternative to what we see basically--I shouldn't say
happening, just not happening--and many of the critical players
on the ground including the PATH group that you saw, many of
the hospitals including Tulane and East Jefferson and West
Jefferson, most of the major players, Dwayne from Charity. We
are trying to come together in a way saying--I think the key
piece for us is to do a pilot program that involves only region
1. That is the area that took the brunt of the damage. It is
something that gets away from what was alluded to as dueling
spreadsheets. The smaller the area, the more precise you can be
with the information about the number of the uninsured, where
they in fact live, where the clinics need, and so forth--
logistical questions around how do you actually get the care to
people. And that is what we have been focusing on. I think by
the end of this month we probably should have something that is
a good start on an alternative system, and I would ask
everyone's patience. Designing health care systems for
coalition of people who have day jobs is a difficult task but I
think one that, given our areas of expertise, that we can come
up with a framework of a credible alternative.
Mr. Burgess. Let me just for one final thought if I could,
we have been focusing on the inflexibility at the Federal
level, primarily through HHS and CMS. Are there any areas where
you can help us with the problem of flexibility that you are
having more at the local or the State level? Are there areas
there where perhaps we need to be focusing some effort, some
energy?
Dr. Quinlan. There is a recent, relatively small
development but is another bottleneck. What we are all trying
to do is find bottlenecks and resolve them. As I understand it,
our own State Licensing Board for physicians has outsourced
that function, and we have noticed there has been a significant
delay now in getting the people we finally were successful in
recruiting into the State, getting them licensed. Our most
recent was a neurosurgeon who is on the payroll but can't get
his license. And he trained at LSU, incidentally, and he came
from Texas.
Mr. Burgess. Now wait a minute. We need him back.
Dr. Quinlan. I know. I will swap you in two draft choices,
maybe.
Mr. Burgess. Mr. Smithburg, you alluded to something about
a cap that is on the reimbursement for public hospitals under
some of the reimbursement. But that is largely a State-imposed
cap, is that not correct?
Mr. Smithburg. Dr. Burgess, that is correct. There is a
State-imposed cap on Medicaid. There is a public program and a
private program, if you will, or all other----
Mr. Burgess. I know my time has expired, but if we work on
flexibility from our end, will you help us work on flexibility
at the State level as well?
Mr. Smithburg. You can count on it. Yes, sir.
Mr. Burgess. Thank you.
Mr. Melancon. Thank you, Dr. Burgess. I recognize Mrs.
Blackburn.
Mrs. Blackburn. Thank you, Mr. Chairman. I thank you all
for your patience and your endurance today.
I am going to start out with a homework question for each
of you, and please understand, going back to the first hearing
that we did in New Orleans following Katrina where we were told
if we can just get some money, if you will just get us some
money down here, we can take care of this. And now we are
hearing from you we can't find the money, we don't know where
the money is. I feel like we are playing a game of Where is
Waldo at some point. So pencils and papers, here we go for the
homework, and then if you will submit this to us we want to be
certain that you all have access to the funds you need, that
you are able to do the work that you need to do. But I think we
also have to--we are not having a hearing on the implosion of
the Mississippi health care system, we are having one on the
implosion of the Louisiana and New Orleans, and so help us work
through this with finding where the money is.
The DRA money, you all were appropriated $2 billion to
Katrina-affected areas. Louisiana got $918.2 million of that.
They have spent $778.7 million. There is $140 million left
unspent. How much have you applied for, how much have you
received, and how much are you waiting to hear from?
SSBG money. You got $220.9 million. $78 million has been
spent, $142 million is left. Same question, what did you apply
for, what did you receive, how much have you not heard about?
DSH, money. You are getting about a billion a year, $250
million has been unspent, and then what are your outstanding
balances with DSH.
Workforce recruitment money. And Dr. Quinlan, I know you
are probably using this on some of those nurses that you are
bringing from----
Dr. Quinlan. We are not. I21Mrs. Blackburn. OK. I thought
with all of these nurses that you were bringing from around the
world from places like Michigan, down south you might need an
interpreter for them, right?
Dr. Quinlan. Right.
Mrs. Blackburn. OK. Workforce recruitment money, Louisiana
has gotten $15 million. They have been sent $15 million. And
then the uncompensated care pool, $120 million has gone to
Louisiana.
So kind of help us as a committee get our hands around, out
of that money what have you applied for, what have you
received, what have you not heard from, so we have a better
idea of what is outstanding. Now, the CDBG money, I know
Louisiana--LSU has a $300 million request in on that I do
believe, and those are specific to you all with LSU.
So anyway, those first five areas, answer those. Mr.
Smithburg, let me come to you quickly. I want to get these in
before we go to vote, so I am going to speed it up, Mr.
Chairman, and see if we can get through this.
LSU is looking at seven neighborhood clinics in New Orleans
as soon as you get through the zoning and the red tape. Can you
not get somebody with the city of New Orleans to help speed
that process along for you all? What is the barrier there? Can
you articulate that for me?
Mr. Smithburg. I wish I could, and the next panel may have
a panelist that might be in a better position to answer that.
It has been an arduous process. We are riding a game plan along
with way with many of these issues, but I am hoping that we are
within 100 days of being able to deploy these mobile clinics
that have actually been sitting in our parking lot for some 8
months.
Mrs. Blackburn. Seven or 8 months the clinics have been
sitting there and all the other hospitals, out of the goodness
of their heart, are soaking up this care and the city of New
Orleans is not approving these clinics, am I stating that
properly?
Mr. Smithburg. Yes, ma'am.
Mrs. Blackburn. All right. Do we know if the problem is
primarily with the State or with the city?
Mr. Smithburg. Oh, I know it is not with the State, and I
believe it is at a point now where an ordinance has been passed
to grant a temporary zoning variance. So we may be a few months
off now.
Mrs. Blackburn. OK. On page 4 of your testimony, you talked
about the VA and moving forward on that. This is an issue that
has been highlighted time and again with us, so speak for the
record briefly about how you all are meeting the needs of the
existing VA population.
Mr. Smithburg. Well, again, I think on the next panel you
will have a representative from the Gulf Coast on that.
Mrs. Blackburn. OK. Do you care to make any further
comment?
Mr. Smithburg. I would note, and thank you for the
question, that the VA LSU Tulane collaborative is really one of
the most exciting, innovative propositions to come before our
market or really any in a long, long time; and should we be
able to receive the CDBG infrastructure funding to get that
launched, I think that is going to be good for preserving,
protecting, and growing medical education as well as of course
re-engaging more beds for the community.
Mrs. Blackburn. OK. I want to go to your comments about the
DSH payments on page 6 and you talked about the methodology.
And reading this, my thought was when you look at Louisiana's
health care system, are you saying that it had some specific
strains and stresses and some amount of brokenness pre-Katrina
and then this has exacerbated the problem? And I would like to
hear how you would respond to that, and then I concur with
Congressman Burgess in looking at what we do to address the
financing situation that you all are dealing with. You know,
the state of the system pre-Katrina and then if there was an
exacerbation of that situation, what degree you would place
with that?
Mr. Smithburg. Clearly before the storm, there were broken
parts of the health care delivery system across the entire
delivery spectrum; and it boiled down to, of course, money, in
my view anyway, that there were not enough resources to cover
the needs of the uninsured, the underinsured.
We are a small business State. Ninety-five percent of our
businesses have 50 or fewer workers. So almost by definition
there is going to be a huge uninsured population. And while
there is a structure I believe in place, a knitted together
fabric of safety-net facilities, it is desperately under funded
and since Katrina and the fact that those antiquated facilities
were wiped out, my brethren here at the table have had to pick
up the slack. And so it is exacerbated indeed.
Mrs. Blackburn. Well, we find it amazing that you are not
able to get approval in the city of New Orleans when your
brethren at the table have been picking up that slack. And to
find that just having been down there in the city holding these
hearings and then to see that there still has not been a real
solution to that issue, it is a touch of a head-scratcher, if
you will, especially with the mobile clinics being sitting in
New Orleans. I mean, it makes you wonder, is there a still
permitting problem? Are we still trying to figure out who is
going to have a hospital that is permitted? So, we are
concerned about that.
I have two more questions that I wanted to get to. I am
going to submit these to you. One deals with your outpatient
facilities and your long-term care beds, the other is going to
deal with the mental health component that you have mentioned.
We will submit those to you, and I am going to yield my time
back so you can get your questions in before we vote.
Mr. Melancon. I thank the gentle lady from Tennessee. Let
me start by asking I guess everybody that is sitting at the
table. Has anybody from the Department of Health and Human
Services come and said to you, ``I am here to help you. Tell me
what it is that you need for us to do so that we can help you
get back up and running?'' At all? Anywhere?
Mr. Muller. I can start. Six days after the storm, actually
Secretary Leavitt, Dr. McClellan, Dr. Gerberding flew into New
Orleans, met with I believe Dr. Quinlan and myself and a
representative of East Jefferson; and that was the start. I
think since then, we have had large meetings. I really haven't
gotten into the details of those, Congressman, but no one has
come to West Jefferson if that is your question.
Mr. Melancon. OK. Anyone else?
Mr. Smithburg. Yes, Mr. Chairman. I would like to note on
the upside, actually, right after the storm the U.S. Public
Health Service, a component of USHHS, has been on the ground
since the storm, is still on the ground, and they have been
miracle workers in my view anyway. And also CMS, right after
the storm, worked with Tulane and LSU to deal with some of the
graduate medical education vagaries as a result of our
facilities being wiped out.
There are numerous other issues that we have enumerated,
but there has been some help, yes.
Mr. Hirsch. Mr. Chairman, after the storm, when Touro
closed and as we were starting to reopen, we actually had the
help of the Public Health Service, we had the 82d Airborne
which was invaluable, we had some National Guard. We also had
others to help us, and from FEMA, we had the DMATs. I think
part of the problem was they left before the population came
back but they were helpful while they were there. But that was
way, way, way before we had population. Colleagues mentioned
some of the other aspects with Secretary Leavitt and some of
the other issues; and then I think just recently with the staff
of this committee coming, and I think once before there was
another group that came in to interview us and that is at least
for me why I am here today.
Mr. Melancon. Well, if I remember correctly, we are over 18
months since the storm and so what I am gathering here is that
immediately they came in and said we are here to help you but
you really haven't seen any help since that. Would that be an
honest expression?
Mr. Hirsch. Well, I think people----
Dr. Quinlan. Are hard at work but they are stuck.
Mr. Melancon. OK.
Dr. Miller. The one agency, Congressman, that needs to be
lauded, it is not directly related to our patient care mission
but certainly health care in general is the National Institutes
of Health who were there from the beginning, have supported the
academic missions of Tulane, LSU, and the other institutions
that do research including Ochsner have been at the forefront,
they have been there for us, and they have come through. So I
want to make sure they get credit for that.
Mr. Melancon. Dr. Quinlan, you said they were stuck. Can
you elaborate on that?
Dr. Quinlan. Well, we have been to a number of meetings in
which many of the principals were at the table with the express
purpose of bringing resolution to some of the problems we had,
but it was unfortunately a continuing story of why they
couldn't do things as opposed to how they would get it done and
that is--this idea of flexibility, the idea of having rules
which are appropriate to the situation as opposed to generic
national rules. I think they were as frustrated as we are by
the process, and that is where the idea of the goal of bringing
people together in a non-partisan way, that there are some
solutions that need to be crafted with the administration and
Congress working together to make sure that these rules that
were created years ago are actually appropriate for today's
problems.
Mr. Melancon. Yes, and I think if my understanding is
correct the way the system works the Secretary of the
Department has the ability to waive rules in special instances.
Of course the inference that I have been getting is this sets a
precedent. The precedent has been set. The storm was a
precedent.
Dr. Quinlan. Yes. If that isn't a precedent-setting event,
I don't know what is.
Mr. Melancon. Yes, I agree with you. And I am going to
submit into the record some numbers that came from--Gulf Coast
recovery numbers--some of the frustration, so that my committee
members will know, there was some legislation in some of these
appropriations that provided that no State could get more than
54 percent of the monies that were appropriated regardless of
the fact whether we had 80 percent or not. There is monies that
I think people need to understand, there are three words, one
is appropriated, one is allocated, and the other is expended.
Appropriated and allocated are the most common you hear,
expended is the one you hear least. As of February 5, out of
$110 billion, about $52.8 billion, and this is across the board
from the Federal Government from our appropriation, has hit the
ground where it counts, and that is where the people are
struggling. We have done disaster cleanup, we have--Small
Business Administration--do you want to hear some really poor
statistics? Dr. Bertucci was talking about it. SBA has received
224,000-plus applications, 102,000 and some change of which
were declined, 87,000 loans have been approved, and only 62,000
loans have been disbursed, totaling $2,932,000 since the storm,
and SBA was allocated $1.7 billion.
Let us talk about the Collaborative if we can real quick.
The three private hospitals. Each of you suggested that one way
to solve the health care access in the region is to reprogram
the disproportionate share monies. How can we do this
specifically, and we can't go on long because of time
constraints. But how can this be done and what rules or laws
need to be changed at both the State and the Federal levels in
order for us to accomplish this?
Mr. Muller. Let me just start and again emphasize the
Medicaid proposed rule to come directly to the providers, us
certify the uncompensated indigent care, and have the money
come direct, don't go through the State. That would be real
easy to do.
Mr. Melancon. OK. Would you all have any problem--as I
appreciated this $250-$300 million are getting left on the
table because of Big Charity being down. Let me walk through
this thought. I don't want to take away the money and then have
some of the concerns that have been expressed here. But if
there is someway to put a sunset over a period of time and
allocate only that money for the use, with that sunset coming
and of course if the time is passed and everything is gone--
what I am trying to figure out is how do I get this Big Charity
building off the table so that we can move forward with health
care and planning for an education facility and a safety-net
facility, whatever it may be? And that is where I am trying to
get. I don't want to take control over the State legislature or
the Governor, whoever he or she may be, and start dictating
what they need to do in the State of Louisiana. So is that some
commonsensical or is that a problem? Mr. Smithburg, let me
start with you because you got the most at stake here.
Mr. Smithburg. Well, certainly I am continuing to get
traction on that VA Collaborative is, I think, paramount in
addition to--and I agree with Dr. Quinlan--getting primary care
system up and running. For some reason, health care redesign
has been morphed into what do we do with the Big Charity
Hospital and the system therein? They are two totally separate
issues.
Mr. Melancon. Right.
Mr. Smithburg. And I think to the extent you can keep those
separate as you have suggested, I think the better for all of
us.
Mr. Melancon. I thank you. Any other comments on that? And
I agree. And that is where I am trying to get. I think that is
the way we make these incremental steps is to put that big
building, because that seems to be the problem or the mindset,
off on the side as we work on the immediate problems.
It looks to me like restructuring the State's
disproportionate share monies will funnel at least some
resources away from the State's charity system in the near
term, and I have that concern as I have expressed that your
hospitals may not pick up your fair share of the truly sick,
even if the DSH dollars follow the patient. Of course, the
expression of cherry pick has been put out there. I am new to
the health care arena, but I am starting to understand; and I
need a firm commitment that you are not going to be turning
away people if we work out the DSH dollars and the services
that need to be applied in the area.
Mr. Muller. I will make that commitment for West Jefferson.
I can't speak for anyone else, but we are doing it, our board--
and I know Dr. Quinlan said here they are here but until we run
out of money, we are going to be there taking care of every
patient that walks in the door.
Mr. Hirsch. I will just say for Touro, we have been doing
it for 154 years, we will continue to do it; and we do it by
the laws of morality. When people come into the emergency room,
our doctors treat them irrespective of their ability to pay and
will continue to do it. And plus, it is the law of the land.
But we do it because it is the right thing to do.
Mr. Melancon. The ER room is different.
Mr. Hirsch. Right, but if there is a system of care in
place that we can participate in, absolutely, we will
participate.
Mr. Melancon. Then can I ask, is there some method that we
can document and track this money over time so that we are
making sure that we keep all the players honest.
Dr. Quinlan. We have to do that to be credible but I--the
dollars follow the patient is such a nice phrase, but I would
like to add it has to be enough dollars follow the patient
because what we don't want is this----
Dr. Quinlan. Well, it is an idea where it looks good and
let us walk away from it. If there aren't enough dollars, then
all this begins to fall apart.
Mr. Melancon. Yes. My time is running out. We have got
votes I think we have got to go take. But let me ask you. You
had the Collaborative. It was sent, it was supposed to deal
with region 1 of the State of Louisiana, and what we were going
to do to try to get that area of the State back up. If I
understand it, all of you were at the table participating in
that original Collaborative, butted heads, knock-down, drag-
out--I have got a nodding no. But the Collaborative went to
DHH. So what you are saying is no, you weren't involved in
the----
Dr. Quinlan. We weren't butting heads, it was a very
collegial approach. It was a clear----
Mr. Melancon. Well, I----
Dr. Quinlan. No, I am serious. We often think that it was
some sort of conflict. The need was so great and our common
interests were so great--yes, we wrung our hands because the
question is do we have enough to get the job done. And we were
not given the task with enough information to address the
broader question. That is why it ended up being a medical home
issue. And it did become--our direction became something that
had to work with the State and as we reconstituted this, we
wanted to go back to region 1 and have something that we could
be more specific about.
Mr. Melancon. Yes, and I have got some further questions
but we need to go and vote. I want to thank you all for being
here; and if there is any contact or expressions that you need
to make to myself or staff, please do not hesitate. We are
going to try and work through this thing over a period of time.
I will turn the chair back over.
Mr. Stupak [presiding]. As Mr. Melancon said, we do have to
vote on the floor. We have 7 minutes left to vote, so we are
going to recess for one-half hour before our last panel.
Thank you all for coming. We will see you all back in about
half-hour.
[Recess.]
Mr. Stupak. The subcommittee will come to order.
We are ready for the next panel. The Honorable Leslie
Norwalk, Acting Administrator, Centers for Medicare and
Medicaid Services, Washington, DC; Dr. Fred Cerise, secretary
of the Louisiana Department of Health and Hospitals; Dr. Robert
Lynch, director of the South Central Veterans Affairs Health
Care Network; and Dr. Kevin Stephens, director, City of New
Orleans Health Department.
As is customary for the Subcommittee on Oversight
Investigations of the Energy and Commerce Committee, I will ask
you all to rise and take the oath.
[Witnesses sworn.]
All witnesses answered in the affirmative. We will start
with Ms. Norwalk, Acting Director for Centers for Medicare and
Medicaid, for 5 minutes, for an opening statement,
STATEMENT OF LESLIE NORWALK, ACTING ADMINISTRATOR, CENTERS FOR
MEDICARE AND MEDICAID SERVICES
Ms. Norwalk. Thank you, Mr. Chairman, members of the
subcommittee. On August 29, 2005, Hurricane Katrina struck the
Gulf Coast just east of New Orleans near Gulfport, Mississippi.
The storm's tremendous impact was exacerbated by the failure of
the Lake Pontchartrain levee around New Orleans on August 30.
With the added blow of Hurricane Rita on September 23, 2005,
more than 4 million people were evacuated, tens of thousands of
businesses, and over 100,000 homes were destroyed. Over 685,000
families were forced to relocate, and at least eight hospitals
were ruined. Over 1,400 people died.
While the storms were devastating and tragic, Louisiana has
the opportunity to embark upon implementing the most far-
reaching improvements in their health care system since the
charity system was created hundreds of years ago in the early
1700's. The heath care system in New Orleans is in essence two
systems, one for the insured and one for the uninsured. There
have been a series of reports and studies both pre- and post-
Katrina that address the deficiencies of the health care system
in Louisiana. There may be debate on the detail, but I would
say that most everyone agrees the system is broken and needs
attention. It is time to level the playing field and provide
the poor and uninsured the same opportunities that those
fortunate enough to be insured have, the ability to receive
quality care and choose their own health care provider.
The infrastructure, economics, and premise of the way the
poor are served in the charity system is outdated and no longer
aligns with today's health care environment. What better way to
roll out a new system of care than to start in the great city
of New Orleans and then extend it to the entire State? This
will require a major educational effort and cultural change,
but I believe as many others do that all Louisiana citizens
will benefit from a new health care system.
The public health and medical crisis across the Gulf Coast
required immediate action to prevent the further loss of life.
Medicare and Medicaid are health insurance programs, however,
and were not designed for disaster relief. This, combined with
the extent of devastation in the region, posed significant
challenges. On August 31, 2005, Secretary Leavitt declared a
Federal public health emergency for the Gulf Coast region
permitting CMS to waive program requirements to ensure the
region's health care needs could be met. CMS proposed to--
proceeded to waiver modify certain Medicare and Medicaid
conditions of participation, certification requirements, and
pre-approval requirements which enabled the remaining health
care infrastructure to deliver vital services.
CMS also quickly established a special multi-State Medicaid
demonstration to help ensure continuous access to health care
services for displaced hurricane victims. Individuals
contemporarily enroll in Medicaid or SCHIP in host State and
receive benefits for up to 5 months. In addition, the Deficit
Reduction Act gave CMS authority to pay the non-Federal share
of regular Medicaid and S-CHIP expenditures in certain counties
and parishes.
Finally, States were able to participate in an
uncompensated care pool to help cover medically necessary
services for evacuees without health insurance coverage.
By January 31, 2006, CMS had granted approval to a total of
32 States or territories to participate in these
demonstrations. Of those, eight were also approved for the
uncompensated care pool.
Turning now to funding, HHS has made available more than
$2.8 billion in Katrina-related funding in fiscal year 2006 to
help respond to the health-related needs of people affected by
the disaster. This includes $2 billion appropriated by the DRA
for payments to eligible States. To date, over $1.75 billion
has been made available to 32 States for a range of health care
items and services, associated administrative costs,
uncompensated care costs, and Medicaid and S-CHIP costs in the
immediately affected Gulf Coast region.
Last month, HHS also made available an additional $160
million for payments to facilities facing financial pressure
because of regional wage changes not reflected in Medicare
payment systems. Finally, on March 31, just a couple of weeks
ago, CMS provided a $15 million grant to promote professional
health care work force sustainability in the greater New
Orleans area.
I want to emphasize that when we distributed these funds
among the States we first consulted with them on their needs
and provided funding based on their requests. Specifically we
have provided $831.6 million to Louisiana. Of this amount,
Louisiana used $130.9 million to pay providers for claims under
its uncompensated care pool. The vast majority of funds
provided to Louisiana, nearly $700 million, was through section
6201 of the DRA. This money was used by Louisiana to pay its
matching obligation under the State Medicaid Program. By
relieving Louisiana of its Medicaid obligation, it is
effectively freeing up the mountain of State funds.
Although the challenges of addressing Louisiana's immediate
and longer-term health care needs have been daunting, they
present real opportunities. Working together, we have the
opportunity to transform the Louisiana health care system. A
recent Public Affairs Research Council describes the system as
``outdated and uncommon, a system that begs for reform.''
The great tragedy and challenges brought by Katrina
galvanized a unified movement to improve health care for the
people of Louisiana. CMS has been an active partner in this
effort from the outset providing dedicated staff, technical
advisors, access to data, and other assistance to assist
Louisiana in a health care redesign collaborative and
developing a practical blueprint for evidenced-based, quality-
driven health care system in Louisiana.
The Collaborative unveiled its blueprint with a concept
paper on October 20, 2006, and CMS has been working steadily
with them since that time to clarify key elements. CMS and HHS
have pledged support for a large-scale Medicaid waiver and
Medicare demonstration to bring about the Collaborative goals,
provided they are consistent with our mutually agreed-upon
principles for rebuilding.
CMS will continue to engage the State in discussions over
how the demonstrations and waivers might be structured and make
expertise available to assist in their efforts.
Thank you and I look forward to answering whatever
questions you might have.
[The prepared statement of Ms. Norwalk appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you, Ms. Norwalk. Dr. Lynch, please, for
5 minutes.
STATEMENT OF ROBERT LYNCH, M.D., DIRECTOR, SOUTH CENTRAL
VETERANS AFFAIRS HEALTH CARE NETWORK
Dr. Lynch. Mr. Chairman and members of the committee, I
want to start by thanking you for the universal support the
U.S. Congress has given to the Department of Veterans Affairs
in its rebuilding and recovery efforts not only in southeastern
Louisiana but along the entire Gulf Coast region. Through that
support, our veterans and the VA employees living along the
Gulf Coast continue to make great strides along the road to
recovery.
Hurricanes Katrina and Rita challenged our country with two
of its greatest natural disasters. While Hurricane Rita did
little permanent damage to VA's infrastructure, Hurricane
Katrina, on the other hand, produced unprecedented damage to
its medical center in New Orleans. Our medical center, the
community we serve, and the homes of veterans and employees
sustained destruction on a monumental scale.
Today I will describe our ongoing and planned health care
restoration efforts in New Orleans. I will speak first to VA
health care recovery activities and its future plans in New
Orleans. Next I will address the Memorandum of Understanding
that was signed between VA and the Louisiana State University
System and actions associated with it. Finally I will discuss
VA's relationship with LSU and the State of Louisiana as the
State of Louisiana progresses in its analysis of State health
care reform.
Forty-eight hours following Hurricane Katrina's landfall,
as quickly as weather conditions permitted, the VA damage
assessment team was dispatched to the Gulf Region to survey the
eight facilities at New Orleans, Louisiana, Biloxi,
Mississippi, and Gulfport, Mississippi. At New Orleans, the
team found the VA facility initially weathered the storm with
minimal damage. However, following the hurricane, water from
the breached levees flooded the entire medical district and the
medical center. Flooding of the basement and the sub-basement
in the main building of the VA Medical Center rendered it
inoperable as these areas housed the facilities, major
electrical, mechanical, and dietetics equipment.
The Medical Center's longstanding academic partner, the LSU
Health Care Services Division, had Charity and University
Hospital sustain similar types of damage. While University
Hospital has reopened, Charity is permanently closed.
In the immediate aftermath of Hurricane Katrina, VA's
commitment to the Gulf Coast region's veterans remains
steadfast. VA deployed a system of 12 mobile clinics, in
coordination with local authorities, to provide urgent and
emergent care to include first aid, immunizations, and
prescriptions. Specifically in Louisiana, mobile clinics
provided care at Baton Rouge, Hammond, Jennings, Kinder,
Lafayette, Lake Charles, Laplace, and Slidell. Those VA mobile
clinics treated 5,000 veterans and over 11,000 non-veterans in
the aftermath of Hurricanes Katrina and Rita.
To address the health care of veterans in the greater New
Orleans area, the VA expanded the capacity of its existing
community-based outpatient clinic, or CBOC, in Baton Rouge. We
converted the ninth and 10th floors of the Medical Center,
formerly the Nursing Home in New Orleans, into exam rooms and
began offering primary care services there in December 2005.
Three months later, in March 2006, limited specialty care
clinics were also added to those units.
Temporary facilities located in Laplace, which is in St.
John's Parish, and Slidell were leased as an alternative--as
alternative sites of care. Tents were erected in Hammond to
provide basic services.
With the support of Congress, the VA was authorized to
accelerate the activation of community-based outpatient clinics
where part of our capital asset--long-term capital asset plan
and opened a permanent clinic in Hammond in August 2006. We
remain in leased space in Slidell and plan to construct a
permanent clinic there in 3 to 5 years. The St. John's
community-based outpatient clinic is anticipated to open in
October 2007.
Basic outpatient mental health services are provided at
each of the clinic locations. Currently inpatient mental health
services is coordinated with the Alexandria, Louisiana VA
Medical Center. Dental clinic services were re-established in
April of 2006 by leasing space in Mandeville, Louisiana. In
Baton Rouge, we leased the old clinic building there in 2006
and are using that facility to house the medical center's
clinical laboratory as well as select administrative support
functions.
As a result of these actions, the southeast Louisiana
veterans' health care system, formerly known as the New Orleans
VA Medical Center, served over 29,000 veterans in fiscal year
2006. This is 72 percent of the previous year's workload in the
year before Hurricane Katrina. In fiscal year 2007, workload to
date is growing at an annualized rate of 10 percent over last
year and is expected to increase as housing is restocked in the
area.
To help our staff and support the community, VA worked with
its academic affiliates, Tulane University School of Medicine
and the LSU School of Medicine to place VA faculty, medical
staff, residents, and student trainees at VA medical centers
throughout our Business 16 network. With the VA's inpatient
units shut down, 102 medical center employees that includes
nurses, health technicians, medical support assistance,
operating room technicians, and certified registered nurse
anesthetists and radiology technologists were temporarily
deployed in July 2006 under a FEMA task order to provide
critically needed staff to support local health care
institutions.
In terms of future VA services in New Orleans, we continue
to explore our long-term options for re-establishing surgical
capabilities and inpatient services in New Orleans. In the
interim, these services are coordinated through sister VA
medical centers in Louisiana, Mississippi, and Texas, as well
as selective referrals to community hospitals in the New
Orleans area at VA expense. We are actively pursuing options
for expanding our outpatient mental health services as well to
meet both current and future veteran needs.
Projects for the re-establishment of radiology and
outpatient pharmacy services on the grounds of the old medical
center are under way and expected to be completed later this
calendar year. In preparation for the construction of a
replacement medical center, VA has initiated its space planning
process. Interviews of architecture and engineering firms to
design the new facility are complete. A selection is expected
this spring. The replacement medical center is expected to
provide acute medical, surgical, mental health, and tertiary
care services as well as long-term care.
As required by Public Law 109-148, VA compiled and
presented its long-term plans for the construction of a
replacement hospital in New Orleans in February 2006. That
report is entitled ``Report to Congress on Plans for Re-
establishing a VA Medical Center in New Orleans''. In that
report, VA identified its principal objectives regarding the
New Orleans area as being not only to restore services to
Veterans in the most cost-effective manner but also to assist
in the restoration of health care and medical education in New
Orleans. Recognizing the successful history for sharing and
collaboration between VA and LSU health care services division,
as well as the potential for future efficiencies, the report
included the construction of facilities on a single campus with
support services shared with LSU was the preferred option.
As a result of the report, VA and LSU leadership signed a
Memorandum of Understanding agreeing to jointly study state-of-
the-art health care delivery options in New Orleans. This MOU
established the foundation for developing a collaborative
approach to operating a replacement facility.
From that, a group of experts from both organizations,
called the Cooperative Opportunity Study Group, or COSG, was
charged with determining if any mutually beneficial sharing
could occur between the two organizations. In the group's June
2006 report delivered to the former VA's Under Secretary for
Health, it concluded that both organizations could leverage
their strengths, provide significant operating efficiencies,
and allow us to better serve our beneficiaries. Congress
subsequently authorized VA to pursue the project to replace the
New Orleans facility as a collaborative effort consistent with
the COSG report.
In September 2006, the Collaborative Opportunities Planning
Group, or COPG, was established to develop an operational plan
for sharing between the organizations based on the foundations
of the COSG. The COPG is co-led by VA and LSU representatives,
representatives of the Tulane University School of Medicine and
the State of Louisiana Division of Administration are also part
of this group and its planning discussions.
A critical component of the charge of the COPG is to
determine if the proposed sharing options identified in the
regional COSG report are viable, and if they are, to begin the
work of developing timelines and formulating the framework for
space planning and design for a joint replacement facility. To
date, the COPG has made significant progress by reviewing
literally dozens of clinical and administrative functions to
determine if the function would best be provided via a sharing
arrangement, between VA and LSU, or independently owned and
operated by both entities.
The final report of the COPG is to be presented this
September.
Mr. Stupak. Doctor, can you summarize, please?
Dr. Lynch. Yes, please. VA remains excited about the MOU
with the LSU in the context of health care redesign in
Louisiana. We support all the principles behind it. At the same
time, health care redesign seems to face some obstacles and
delays in Louisiana. Because of this, we are committed to
exercising due diligence to our veteran beneficiaries and to
the taxpayers and are concurrently exploring other options for
initiating reconstruction of our VA Medical Center in southeast
Louisiana. In furtherance of this, we plan to begin a site
search to identify alternative locations in the near future
while we continue our work with LSU on our collaborative plans.
In conclusion, Mr. Chairman, we consider the committee and
Louisiana delegation to be partners with VA and seeing the
southeast Louisiana veterans continue to receive high-quality
health care that they have come to expect and deserve. Congress
appropriated over $1.2 billion supplemental funding for
recovery and rebuilding efforts in VA. This includes $625
million for the construction of our placement medical center in
New Orleans.
Our commitment to outstanding health care for veterans will
continue as well our collaboration/exploration with LSU.
Thank you for the opportunity to be here today. I
appreciate it, and I will take the opportunity to answer any
questions.
[The prepared statement of Dr. Lynch appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you. Dr. Cerise.
STATEMENT OF FRED CERISE, M.D., SECRETARY, LOUISIANA DEPARTMENT
OF HEALTH AND HOSPITALS
Dr. Cerise. Thank you, Mr. Chairman, and members of the
subcommittee for the opportunity to testify today on the
continuing concerns and immediate health care needs in the New
Orleans region.
Let me start by saying I have heard Congressman Dingell's
directive earlier this session and commit to you that I will
call Secretary Leavitt's office upon leaving here today and
discuss follow up of this discussion that we are having here.
You have heard much about the loss of compassion in the
health care delivery system in the New Orleans region, from
preventative services to acute care, hospital services to post-
acute and long-term care services.
Our challenge is twofold, to first meet immediate needs
while second, ensuring that in the process we support the
rebirth of a better overall system of care, particularly in the
Katrina and Rita affected areas. This vision is for a system to
replace the loss capacity. It is one that adheres to the aims
set forth by the Institute of Medicine. It is a patient-
centered system predicated on access to primary care
coordinated among providers, supported by a system of
electronic medical records to improve safety, quality, and
efficiency.
The current gaps in the delivery system created by Katrina
have provided the opportunity for that type of system's change.
As we move forward with the health care reform for Louisiana,
we must also ensure that the New Orleans region can recover to
meet our citizens' health care needs today.
My testimony today will focus on the short-term health care
needs in the New Orleans region. Louisiana appreciates the
assistance Congress has provided for health care. For example,
$680 million in Medicaid relief and $134 million in
uncompensated care reimbursement which came at a critical
juncture in early 2006 as the State was implementing budget
cuts in almost all programs including health care. The State
actually had a rule that we had issued cutting reimbursement
payments to Medicaid providers by roughly 10 percent across the
board.
Subsequently the State has been able to provide assistance
including $52 million in uncompensated care for community
hospital services rendered during fiscal year 2006, $120
million in uncompensated care for community hospital services
during State fiscal year 2007, $38 million to increase Medicaid
payments to hospital and in an attempt to sustain capacity for
post-acute care, direct service workers caring for elderly and
individuals with disabilities in the Medicaid program received
a $2 an hour salary increase at an annualized cost of $110
million.
Still more assistance is needed to meet the extraordinary
needs that we are faced with. I am going to summarize a few
areas. You have heard about these earlier today as well.
Primary care capacity. Using Federal standards, we have a
shortage of 49 primary care physicians in the New Orleans
region available to serve the Medicaid uninsured population
which is affecting all other components of the system. We
propose to establish primary care capacity in a manner
consistent with the redesigned system of care envisioned by the
Health Care Redesign Collaborative by sustaining operational
support provided by SSBG funds to safety-net clinics and by
funding new medical homes of sufficient size and scope to meet
the needs of the uninsured population.
Still roadblocks to increasing access to outpatient care
include the inability to use disproportionate share, or DSH,
funding for non-hospital based care and the inability to use
DSH to reimburse for physician services remains an issue. In
order to receive DHS funds today, health care services must be
funded through a hospital. While the State has created great
capacity in a clinic system associated with public hospitals,
current DSH rules limit flexibility and development of further
outpatient capacity.
We propose that the State be allowed flexibility to use DSH
funds to support non-hospital based clinic care and allow DSH
funds for physician services. This solution does not require
additional Federal funding, just flexibility.
In terms of workforce recruitment retention, you have heard
a lot about this already. The New Orleans region is
experiencing shortages of physicians, behavioral health
providers, nurses, other professional staff, and competition
for workers is high including rising labor costs, lengths of
stay in hospitals are increasing. I would point to two
solutions. You have heard about one in terms of the Medicare
wage index. The Medicare calculations do not account for the
unforeseen labor cost increases seen in the region post-
Katrina. HHS awarded Louisiana $71 million one-time grant to
address this. That is certainly helpful. Hospitals and skilled
nursing facilities estimate this is about one-third of the need
to address this increased wages relevant to the Medicare
program.
Second, to date the State has received a $15 million grant
from HHS to fund the Greater New Orleans Health Services Corps
to provide incentives for physicians, dentists, nurses, and
other professional staff to meet the needs in the region. We
requested funding for this program. We think that program would
cost--our estimates are $120 million to fully supply and meet
the needs in the region today, and so we would ask for that
support. In exchange for the financial support, providers must
commit to serve in that region for 3 years.
And then finally in the area of behavioral health, the
shortage of community services that we had prior to Katrina was
exacerbated by the hurricane resulting in greater reliance on
an already-crowded hospital emergency infrastructure. In
addition, we have lost psychiatric beds in the area. We propose
funding and implementation of a 5-year plan for behavioral
health services and expending Medicaid coverage to people with
severe mental illness. This 5-year plan would include direct
treatment dollars for the full continuum of behavioral health
care as well as continued funding of the existing FEMA disaster
relief grant for crisis counseling.
The concept paper put forward to HHS also included a
request to include those individuals with serious mental
illness as a Medicaid eligible population. This would allow us
to provide broader access to services for these individuals.
I have outlined other needs in my written testimony,
including such things as support for implementation of
electronic records as was pointed out earlier today, as well as
section 8 housing vouchers to be used with permanent supportive
housing for people with developmental disabilities.
I appreciate your continued interest in the recovery of the
greater New Orleans region. The State has worked
collaboratively with Federal the city officials as well as
community providers, and I have heard your directive earlier
today and commit to continue this work to address those
critical needs highlighted today.
Thank you for the opportunity to testify.
[The prepared statement of Dr. Cerise appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you and thank you Dr. Cerise. I noticed
you have been here all day, so I appreciate that. Dr. Stephens?
STATEMENT OF KEVIN U. STEPHENS, SR., M.D., DIRECTOR, CITY OF
NEW ORLEANS HEALTH DEPARTMENT
Dr. Stephens. I am Dr. Kevin Stephens, the director for the
New Orleans Health Department. To Chairman Stupak and the
Ranking Member Whitfield, and distinguished members of the
Subcommittee on Oversight and Investigations, thank you for
inviting me here today to speak on the state of health care in
New Orleans. Mayor C. Ray Nagin and his administration welcome
dialog, and we are hopeful that this hearing will spur positive
change as we work not only to rebuild our city's infrastructure
and neighborhoods, but also to develop a state-of-the art,
modern health care delivery system.
I would like to acknowledge and thank Secretary Michael
Leavitt who was represented by Ms. Norwalk, for all the support
that the Department of Health and Humans Services has given to
the City Health Department specifically. And in fact, Secretary
Leavitt--I first met him on August 24, 2005, less than 1 week
before Hurricane Katrina. We both visited the Pontchartrain
Senior Citizen Center and spoke with community leaders and
senior citizens about Medicare. We developed a professional
relationship which has continued in the aftermath of Hurricane
Katrina, and additionally I would like to thank Dr. Cerise for
his support of this city as well as Dr. Lynch of the Veterans
Affairs; and we are looking forward to having a long,
productive relationship with the Veterans Affairs and we are
looking to strengthen our partnership with them.
I want to just three or four things here, talk about the
pre-existing problems and Katrina's impact on it, the role of
the New Orleans Health Department, mental health, and some
recent mortality trends that we have observed.
Since the storm and floods, only four of the eight
hospitals in the parish have reopened at decreased capacity.
The City Health Department which employed more than 200 health
professionals lost more than 60 percent of its staff and closed
eight of its clinics. Yet, as traumatic as this devastation
was, it has given us a unique opportunity to redesign and
rebuild a model health care delivery system that corrects the
gaps and failures of the past.
The New Orleans population, which was more than 450,000
people before Hurricane Katrina is now estimated to be between
230,000 and 250,000 citizens. Even with this temporarily
reduced population, approximately 20 percent of our citizens or
more than 30,000 people are uninsured. The city has a rapidly
increasing indigent worker population, some of which speak no
English. In providing health care services, these citizens has
placed such a tremendous burden on our health care providers of
the surrounding parishes and those that are in New Orleans.
Another challenge has been the decrease in the number of
health care providers. According to a 2006 Blue Cross/Blue
Shield report, New Orleans had 2,038 physicians pre-Katrina and
only 510 physicians post-Katrina. This is a 72 percent decrease
which highlights the relative loss of medical professionals.
Other evidence can be found in a study conducted by the
Louisiana State Department of Health and Hospitals where out of
202 primary physician who responded, only 154 were still
practicing, and only 73 accepted patients dependent on Medicaid
as a source of payment. Clearly, more providers are needed in
Orleans Parish, particularly those who care for the uninsured
and underinsured.
There is a similar story as it pertains to the capacity of
Orleans Parish hospitals. According to the 2006 report by
PriceWaterhouseCooper, New Orleans had 2,258 beds before
Katrina and according to a recent report by Metropolitan
Hospital Association, Orleans Parish now has 625 staffed beds,
a reduction of 75 percent.
Fortunately, our neighboring Jefferson Parish, they have
lost far less capacity; and with its number of hospital beds
decreasing from 1,922 to 1,636, Jefferson Parish hospitals have
been responsive in absorbing patients from Orleans Parish. But
this not negate the critical need for more hospital beds to
open in Orleans Parish and to meet the needs of our ever-
increasing population.
The City of New Orleans Health Department must play a
significant role in improving the health of the residents of
our city. We need to full staff our clinics and expand the
offering to include all preventative and primary care services.
Since health outcomes are largely controlled by personal
lifestyle choices, public health professionals must play a
critical role in educating the public about health risk and
behavior modification. We think this is the ultimate solution
because that is how you really decrease primary care--and
hospital beds is by getting people to change their personal
lifestyle choices.
Mental health, the provision of mental health services pose
a particular challenge in this region, an that has experienced
severe loss, death, and destruction. And so we think that
despite this need, it has fewer than 50 hospital beds for
inpatient psychiatric care, about 17 percent pre-Katrina
capacity.
And finally, the mortality rates, as a doctor and health
care provider, I noted a dramatic increase in the number of
death notices in the newspaper. This observation was supported
by further deaths of two of the staff people of my own
department within a short period of time and anecdotal accounts
of families going to more funerals than ever. Due to the lack
of State data for this problem, we engaged in a count of death
notices in the Times-Picayune and compared it to a parallel
period before Hurricane Katrina.
To validate our methodology, we compared the number of
deaths notices printed in the newspaper in 2002 and 2003
compared to the published State data from death certificates.
In both cases, we noted the difference between the two was not
statistically significant. In 2003 we averaged 924 deaths per
month according to death notices. In contrast, for the first 6
months in 2006 we averaged 1,317 death notices per month. This
means that approximately 7,902 citizens expired within the
first 6 months of 2006 as compared to 5,544 for the first 6
months in 2003. The observations as well as the severity of
health problems treated in our Health Recovery Week strongly
suggest that our citizens are becoming sick and are dying at a
more accelerated rate than prior to Hurricane Katrina.
We believe these findings are significant, but the city has
reached it limits as to its ability to research this important
issue. It is critical that the State and Federal agencies
immediately study these trends as well as the cause of death.
This information can be used to develop appropriate
intervention.
In conclusion, clearly the health care system in New
Orleans is far from normal, and we are working diligently to
make improvements. The City of New Orleans Health Department
has three proposals to comprehensively and systematically
rebuild our health care system.
Number 1, all citizens should have immediate access to
primary, preventative, and mental health care services. People
are suffering now and we must respond.
Number 2, the city needs more hospital beds. The shortage
of hospital beds has reached a crisis proportion and on some
days ambulances have to wait hours on emergency room ramps to
offload patients.
Number 3, we must receive the resource to rebuild the New
Orleans Health Department. Our Health Department is a necessary
partner in the repair and reconstruction of the city's health
care delivery system.
Our health system has serious inadequacies and gaps prior
to Hurricane Katrina, but the storm ruptured it to a point that
many more of our citizens have lost access to health care
services.
I would like to thank you for your attention to New
Orleans, and we look forward to working with you to solve these
problems.
[The prepared statement of Dr. Stephens appears at the
conclusion of the hearing.]
Mr. Stupak. Thank you, Dr. Stephens. Doctor, if I may, you
indicated and I was a little surprised by the statement that
the number of deaths since Hurricane Katrina was not
statistically significant, yet we have had another panel say
they are up about 48 percent. I think if you look at the Times-
Picayune newspaper obituaries before Hurricane Katrina, you had
about 30 a day. Now you are averaging about 60, 61 a day. That
is a rather significant increase in the number of deaths per
month since Hurricane Katrina.
Dr. Stephens. Yes, and I said they have been significant. I
didn't say they were insignificant.
Mr. Stupak. Then I must have misunderstood you. My
apologies if I did. Let me ask you this. In the Times-Picayune,
there was an article, Friday, March 10, about the trailers that
came 9 months ago. There are eight exam rooms that were
supposed to be strategically deployed around the city and we
are still waiting for a permit. Can you tell me what is the
status of that?
Dr. Stephens. Well, the permitting is not in the prevue of
the Health Department----
Mr. Stupak. I realize that.
Dr. Stephens. I can tell you what I know.
Mr. Stupak. OK.
Dr. Stephens. In the city council meeting a week ago they
passed the zoning variance they needed for the placement of the
trailers in the school zone.
Mr. Stupak. We are all set to put those trailers out there?
Dr. Stephens. Well, I am not sure where they are in the
process. I know they got the biggest hurdle which is getting it
through city council. But as I reflect back upon it, a couple
things, one----
Mr. Stupak. You have to provide a certificate as public
health?
Dr. Stephens. No.
Mr. Stupak. OK.
Dr. Stephens. I have nothing to do with that process at
all. But when it came to my attention, I did go and ask what we
could do to help.
Mr. Stupak. Dr. Cerise, there was a question earlier or a
statement earlier about the nurses, volunteer nurses coming in.
I think it was with Operation Blessing where at the end of the
month they can that be resolved between now and then end of the
month?
Dr. Cerise. Listening to the earlier testimony, I checked
with the Board of Nursing and the process--and they are not
aware--they are not denying nurses access to the area. Unless
there is a credentialing problem, inability to verify
credentials or something like that, they are not doing that;
and they told me that they don't have plans to do that.
Mr. Stupak. Would you get Mr. Koehl after this and get this
thing----
Dr. Cerise. We will make sure we make clarify that. And if
I could on the death rate, we did our office of Vital
Statistics did look at this a little bit over a year after
Katrina, and it is tough to come to a rate when you don't know
the population for sure. And so we were able to do some
comparison before in 2004-05 and 2005-06 and the number of
deaths of people from New Orleans who are residing in
Louisiana, where we would have a death certificate on them, was
about 41 percent of the deaths in a prior year period. We also
have that broken down by cause of death and we----
Mr. Stupak. Right, but I understand we have less people now
in New Orleans than we did before. So if it was 31 deaths
before with a full New Orleans and now we got half of New
Orleans and we got 60 deaths, that is a tremendous----
Dr. Cerise. That is where I said the difficulty is with a
moving population, but looking at absolute numbers, it was
about 41 percent a year after.
Mr. Stupak. Would you work with Dr. Stephens to get that
one resolved? Ms. Norwalk, in your testimony on page 4 you
indicate CMS established a special 1115 Demonstration Waiver
Program to help insured, continuity of health care services for
victims of Hurricane Katrina, basically the evacuees, correct?
Dr. Cerise. Absolutely.
Mr. Stupak. Why can't we put a program----
Ms. Norwalk. That is the way that the DRA funds work it----
Mr. Stupak. Why can't we do a special demonstration
project, waiver 1115 for all of New Orleans right now? We have
a number of things besides money. We have community health
centers that have been applications pending before Hurricane
Katrina struck still not approved. We have got the volunteer
nurse issue which I think we might have resolved. We have an
underserved area, we need health information technology, we
need PATH to specialty services, workforce development, you
name it, we got a number of problems. Why can't we get together
and do a special demonstration project because things are not
very well here in New Orleans?
Ms. Norwalk. Well, that is what we have been working with
the State to do, in fact, is to work both on a Medicaid waiver
as well as doing Medicare demonstration.
Mr. Stupak. OK. But you rejected The Cooperative plan which
is really for region 1, wasn't it?
Ms. Norwalk. Well, it was a concept paper that was
submitted by the State on behalf of the Collaborative. I
wouldn't say that we rejected it. We had been working with the
State to figure out what it is that the State wants to submit.
I can ask Fred if that was a waiver that was submitted or
merely concept paper that----
Mr. Stupak. Well, wasn't the Collaborative--wasn't that
really sort of like to put a pilot program in region 1, those
four parishes we have been talking about today to try to get
health care delivery system as quickly as possible up in New
Orleans?
Ms. Norwalk. We submitted our paper.
Dr. Cerise. What we were asked to submit was a concept
paper by October 20 which we submitted for the New Orleans
area. I think some of the earlier discussion has been in terms
of the rejection of that. We are still in discussion with CMS
on this issue.
Mr. Stupak. What are the issues that have to be resolved?
Our goal here is to get, like yours, is to get health care back
to--what else has to be done here to get this region 1
Collaborative effort going here? What has to be done? What
waivers do we need at both the State level and then we will go
to the Federal level?
Dr. Cerise. We have stepped back--the State has--look, we
put forth a concept paper and I apologize going into some
detail but it is rather complex. We put forward a concept paper
working in cooperation with CMS that said this is how you could
insure the population in this region. And by using Medicaid
savings, restructuring Medicaid, and shifting DSH funds to an
insurance product.
Mr. Stupak. OK. This was region 1, these four parishes?
Dr. Cerise. That is correct.
Mr. Stupak. And HHS did not accept that?
Dr. Cerise. In discussions after October 20th we were told
they would not do a region-specific demo----
Mr. Stupak. But a statewide demo?
Dr. Cerise. It would be statewide. So we started working on
a statewide number.
Mr. Stupak. We shouldn't be worried about statewide
situation right now.
Ms. Norwalk. Actually there are a couple points I would
like to make to that. First in doing this--in fact it was
Secretary Leavitt's initial proposal to do this on a region 1
specific basis or greater New Orleans basis.
Mr. Stupak. Answer me this. The Secretary can't be happy
with the health care system being delivered in these four
parishes.
Ms. Norwalk. Absolutely. That is correct.
Mr. Stupak. So why would you reject the Collaborative and
come up with a statewide plan?
Ms. Norwalk. Actually we haven't and in my opening
statement----
Mr. Stupak. All right. You haven't rejected it, you haven't
approved it.
Ms. Norwalk. They haven't submitted a waiver to us. They
have submitted a concept.
Mr. Stupak. Have you told them they have to submit a waiver
with this Collaborative?
Ms. Norwalk. I think it is without question known that they
need to submit a formal waiver.
Mr. Stupak. Have you told the State that?
Ms. Norwalk. Yes, absolutely.
Mr. Stupak. OK. Today or earlier?
Ms. Norwalk. Oh, this has always been the issue since we
have been down there for a year-and-a-half that the State would
need to submit a waiver to us formally as they do for other
waivers that they have submitted to the Agency.
Mr. Stupak. OK. Dr. Cerise did they tell you you have to
submit a waiver to get this Collaborative effort in?
Dr. Cerise. We are aware that to get a waiver that there is
a formal application process.
Mr. Stupak. OK. Have you submitted that application?
Dr. Cerise. No, we haven't.
Mr. Stupak. Do you anticipate submitting that application?
Dr. Cerise. What we anticipated doing was getting to a
level of agreement so that we know when we would submit a
waiver it would be an acceptable waiver. There is a lot of work
that goes into that piece. And we were working with CMS to try
to get to that point. It became clear to us in that process
that the dollars needed to do what we were comfortable with,
and that was insuring a significant portion of the population
with existing funds, with no new funds. We are going to be much
more than we had in existing funds. We were working through a
number of assumptions with CMS. In about mid-December, those
discussions stopped until we received essentially the set of
spreadsheets that you referred to earlier in January.
Mr. Stupak. So you are getting into an actuarial battle
then, right, on cost, pennies, and things like this, right?
Dr. Cerise. That is correct.
Mr. Stupak. That is what we don't have time for, right?
Dr. Cerise. That is correct.
Mr. Stupak. OK. Here is what I am going to do on this
Collaborative. We are going to ask HHS to provide us all
documents going back and forth. The committee has been trying
to get our hands on it. So you can expect the document request
from this committee on that. And so we ask you to preserve the
documents and statements along those lines there.
Ms. Norwalk. If I can make just one comment, Mr. Chairman,
about the issue about the issue of region 1 only.
Mr. Stupak. Sure.
Ms. Norwalk. While it makes a great amount of sense to
start in region 1, I want to note the disparities that would
occur if that were the case. In region 1, if you said let us do
this proposal and cover those who are 200 percent of the
poverty level or below that would mean a family of four could
be earning $41,000.
Mr. Stupak. That is fine.
Ms. Norwalk. It is great.
Mr. Stupak. It is fine with me.
Ms. Norwalk. However, in region 5 that has been hit by Rita
and actually a number of other regions, that same family of
four could only earn $2,600 in order to qualify for Medicaid
under the same thing. That disparity is something that concerns
us if it is long term. So when working with a statewide,
appreciate rolling it out, region 1 is of what is critical
importance to deal with New Orleans, there are issues that the
State is going to need to consider because you wouldn't want an
influx of people to New Orleans when the system is not yet
ready to handle that from an infrastructure perspective. Not
that it wouldn't be great medium term----
Mr. Stupak. Well, my concern is region 5 has health care,
region 1 does not. My concern is also there is a 115 waiver
waiting, according to Dr. Wiltz, for 287 health care clinics
that were before Hurricane Katrina and they are still not
approved, right?
Ms. Norwalk. I don't now if that is a 115 waiver on----
Mr. Stupak. Well, there is a waiver pending. I might have
my number wrong.
Ms. Norwalk. I can check with staff. There may be something
pending elsewhere.
Mr. Stupak. Here is my concern. 9/11 hits New York, they
have their waiver pending, that is approved, no questions
asked, no further documentation. New Orleans, we have been
waiting 18 months, even more than that, and we still have
waivers pending before HHS not approved. When I was down in New
Orleans a year ago and we asked the question about waiver that
they needed then, I think it was for the GME, for graduated
medical, and were told they filled out the wrong form. But you
never told the people that. We are getting a little frustrated.
Ms. Norwalk. We actually did the GME in a rule so they
wouldn't need a waiver for the future, and we have solved that
problem for the next 3 years. So from a GME perspective, we
have been verifying----
Mr. Stupak. What can we do that is going to be unique? Why
can't we demonstrate a project here? There is a great need here
for health care.
Ms. Norwalk. Absolutely.
Mr. Stupak. Why can't we get with HHS, get with the State,
the city, and provide the reimbursements they need, the nurses,
the clinics, and get this thing moving?
Ms. Norwalk. The other piece that I think is important to
note is----
Mr. Stupak. No, how about answering my question.
Ms. Norwalk. In answer to that question I am more than
happy to sit down with you at any point in time.
Mr. Stupak. I want you to sit down with the State, the city
and them. I don't know about New Orleans.
Ms. Norwalk. We do that on a continual basis. We have been
working with the State for pretty much every day. We have
people embedded at the----
Mr. Stupak. Very good. You want to make a statement there,
though?
Ms. Norwalk. Yes, I did actually want to point out that the
$2 billion in DRA funding, the $164 billion went to cover the
evacuees and the State share as well as those who are impacted
within Louisiana. Over the last month we have distributed $175
million across the Gulf Coast region. $71.6 million went to
address the Medicare wage index's disparity with hospitals----
Mr. Stupak. You can spare us the stats because all the
other panelists told us there is not enough in the system. They
are not getting the money. And you could have released $2.8
billion but it all didn't go to health care, it went to many
other places. Our concern is get health care up and running.
Ms. Norwalk. Just one other point is that there is some
additional funds from the DRA. We anticipate about $170 million
as we collect that back from the other States that did not
spend the DRA funds on impacted individuals and evacuees. We do
intend as we can under the DRA to reallocate those funds, much
like we did with the initial $175 million so that we do hope to
support a number of the concerns that they have in terms of
short-term needs.
Mr. Stupak. I am sure you saw the article. It has been
referred to repeatedly today in the Times-Picayune about
hospitals running out of space, they don't have bed space. You
have heard that all over the place.
Ms. Norwalk. Absolutely.
Mr. Stupak. So all those numbers are fine but they don't
solve the problem. We need these things resolved. We need them
now.
Ms. Norwalk. And if I might add to that, not only do the
problems that we have to resolve that issue is far beyond the
health care fund. They need housing, they need education, they
need to be sure they are safe and secure.
Mr. Stupak. Absolutely.
Ms. Norwalk. They have population shifts, difference with
income, so this is more than just making sure that the health
care system dollars are there. It is actually far beyond that
so that the staff can come into New Orleans and help support
that. And that is really----
Mr. Stupak. But we need cooperation from everyone, the
Federal Government, State, local.
Ms. Norwalk. Absolutely.
Mr. Stupak. And next time I would appreciate your testimony
before 7:00 so our staffs have a chance to go through it.
Ms. Norwalk. No problem.
Mr. Stupak. And with that, let me turn it over to ranking
member, Mr. Whitfield.
Mr. Whitfield. Thank you, Mr. Chairman, and I want to thank
the panel for being here. Prior to your testimony, we heard the
testimony of 13 health care professionals in the area; and
every one of them pointed out the many problems that they face,
the shortage of primary care providers, a shortage of
specialty, a shortage of hospital beds, a shortage of
psychiatric help. All of those are problems, and it has been a
year-and-a-half since Katrina hit. There have been millions of
dollars appropriated and sent to New Orleans and when you hear
reasons why we have not done a better job of having an
effective health care delivery system in place today, you can--
health care is so micromanaged you can always come up with,
well, this waiver wasn't given or the poverty level was too
high here or poverty level too low here or whatever, whatever,
whatever. But Ms. Norwalk, you are very familiar with all these
regulations, and Mr. Cerise, you are familiar with all these
regulations, so I would just ask the two of you what could be
done to expedite this? I mean, I know that each one of you
could go on and give 30 minutes of reasons why we haven't done
a better job of providing primary care when you consider the
money given. But from your perspective, Ms. Norwalk, what is
the problem? Why can't we do a better job at this?
Ms. Norwalk. Well, there are a number of different issues.
First of all, I would note that particularly Medicare is not
really set out to help with disaster relief and recovery. So
the first issue that we have when we say, oh, what can we do to
help? I think we have done a fair amount to try and help where
it is that we can, given that this is a national program.
The second issue is Medicaid. Medicaid is a State-run
program where the State is in partnership with the Federal
Government, and the Federal Government provides matching funds.
But the State has the lead. And the fact of the matter is much
as you reference in terms of micromanagement, the Federal
Government does not want to do micromanagement of what happens
in Louisiana. It is not appropriate. It is their health care
system. And that was one of the key principles, and when we
first sat down with the State in September and October 2005,
that is--not just the State but the entire community, that was
really the number one key. So when working with the State and
the Collaborative, I think that we have a very good framework
to move forward. And there is no doubt that there will continue
to be debate about the numbers internally. There always is
between the States and CMS whenever you are looking at Medicaid
programs. But I think that those are things that we can get
beyond in order to make sure that people in Louisiana have
insurance or a medical home or stop going to emergency
departments to receive care, for example, which helps--which
exacerbates the emergency department overcrowding problem that
we have. I think there are a lot of things that we can do and
are doing with our short-term needs and additional DRA funds to
help support getting back recruitment and retention. So getting
physicians back, helping with mental health, helping with long-
term care, again to get people out of the hospital.
Mr. Whitfield. You know, my understanding the insurance is
not a problem, having the providers provide care is the
problem.
Ms. Norwalk. Well, I think you got--well, that may be the
case. I think you may have--you have got a long-term issue. If
you want people to come back to New Orleans, physicians and
other staff, direct service workers, to come back to New
Orleans, they are going to need to know that they have a large
patient base and can actually earn a living; and to do that, I
suspect that more of them would be interested if they had a
wider base, i.e. more insured.
Mr. Whitfield. Mr. Cerise, from your perspective, what is
frustrating about this for you? What needs to be done?
Dr. Cerise. Well, we have a difference of opinion on how we
would attract providers back into the area.
Mr. Whitfield. Well, if you have a difference of opinion,
who makes the final decision?
Dr. Cerise. Well, we were engaged in a collaborative
process. The Collaborative put forth this concept that focused
heavily on the delivery system and said that we have lost a lot
of capacity. We would like to put the pieces together in a way
that is a more coordinated system of care, and we brought that
concept in September to CMS and made this case. We have got a
lot of capacity needs. If we could put some--a stake in the
ground, put a significant capacity, primary care providers,
organized in a particular way so that whether they are seeing
insured people, uninsured people, they are reimbursed not for
episodes of care, not for episodes of illness, but to manage
the population, to attract people with chronic disease, to be
connected with electronic records, to make a significant impact
of a new system of care in a devastated area, create a new
model of care delivery. And what--the reaction that we got from
Dennis Smith at CMS was essentially go back and bring us back
an insurance model that moves DSH dollars to cover people
with--to insure the population.
We went back and worked on that. I can tell you, what you
heard earlier today was a cry to say can you support, with some
certainty, some income for these clinic sites so that we can
bring enough capacity back into the region because I don't
think as the initial step--we can--it is an interesting debate
and we can talk about whether swapping DSH funds for insurance
is a smart thing to do long term and cover for more people. But
for the immediate impact, I think that swap is not going to
make the same impact as funding some delivery sites throughout
the city where you have got a huge gap in capacity.
Mr. Whitfield. You know, you get the impression just
listening to this that there is so much emphasis being placed
on the Collaborative and what the health care system in
Louisiana is going to look like in the future, that taking
steps to get a primary health care system, delivery system into
place to take care of the needs today was placed on the back
burner. Would you disagree with that?
Dr. Cerise. I think that that is a fair assessment. We have
tried to take the approach of while we have a broken system,
put the pieces back together in a way that is good for the
future, that makes sense for the future. But there is critical
capacity that we have to replace today, and I think we have----
Mr. Whitfield. It sounds like we need to focus more on just
meeting the needs today and then talk about the future later
from our perspective. One other question. Dr. Cerise, it is my
understanding that nearly $250 million in DSH monies are
currently not being utilized and will expire at the end of the
fiscal year if not used. What can and needs to be done to use
these funds today?
Dr. Cerise. Well, actually we have less than that
available. The States got a DSH cap of a little bit over $1
billion, and we project that we will spend about--a little bit
more than $950 million or somewhere in that range of DSH. And
so the limiting factor on the State drawing down DSH funds for
now is State match, putting up 30 cents on the dollar and match
to draw that down and having the allowable costs to spend that
on. In the prior years we were not at our DSH cap but we are
getting very close to our DSH cap right now and certainly there
is not $250 million unspent DSH available this year.
Mr. Whitfield. OK. Mr. Chairman, I yield back the balance
of my time.
Mr. Stupak. Ms. DeGette from Colorado for 10 minutes?
Ms. DeGette. Thank you, Mr. Chairman. Ms. Norwalk, I want
to explore the Secretary's health insurance proposal a little
further because I am a little unclear about some of the ideas
in the concept. From what I understand, is the general concept
of this plan is that you would take DSH monies and rather as
happens now in Louisiana where the DSH monies go directly
through the charity system, what would happen under this plan
is that the DSH monies would be given out to the uninsured to--
they would be used to purchase private insurance for those
individuals, is that correct?
Ms. Norwalk. That is part of the concept, that is correct.
Ms. DeGette. What is the rest of the concept?
Ms. Norwalk. The way that the proposal is structured really
is intended to focus on what the State needs are first, and
there is no question that the State has raised a concern that
there be DSH funds remaining so they continue to have a safety
net. So part of that is redirection of some DSH dollars.
Ms. DeGette. OK. Is there any sense through the Secretary
what percentage of the DSH dollars would be needed to purchase
this private insurance for the uninsured individuals and what
amount would be reserved for the other individuals?
Ms. Norwalk. It really is up to the State, but it depends
on a number of different options. And one of the things we have
done is provide the State with a tool to help figure out if you
have dialed up or down certain things such as the number of
people you want to cover, the poverty level that you cover, the
benefit package that is provided and the like.
Ms. DeGette. The reason Mr. Stupak was cutting you off and
the reason I am cutting you off, and I apologize, and you can
certainly supplement your answers in writing is we only have 10
minutes to question the witnesses. So I guess the answer would
be that you don't have a firm answer about percentages because
it would depend on a lot of variables.
Ms. Norwalk. Correct.
Ms. DeGette. Thanks. Now, is this plan similar to the
Massachusetts connector plan?
Ms. Norwalk. Again, it is really up to the State in terms
of what they want to put together, but there are a number of
things that both Massachusetts, California, Indiana, Michigan--
a number of States have looked at this type of model. Each plan
is different.
Ms. DeGette. In fact, Massachusetts plan covers everybody,
not just the uninsured.
Ms. Norwalk. Correct.
Ms. DeGette. It engages the employers and it engages the
insurance company.
Ms. Norwalk. That is correct.
Ms. DeGette. So what you are saying is Louisiana could do
something like that but you are not giving them the details,
you just think--here is a pot of money for DSH. You guys could
use it to insure uninsured people.
Ms. Norwalk. One of the concerns they have is to have DSH
dollars go to physicians and clinics, for example.
Traditionally, DSH does not go to physicians. Disproportionate
share hospital payments go to hospitals.
Ms. DeGette. Yes, as I said before I am very familiar with
DSH.
Ms. Norwalk. Right. I apologize. So appreciating that
issue, wanting to be sure if you were going to divert that
money in some other way that we can do much as Dr. Cerise has
suggested is necessary, and much of the testimony here has been
we need to have funds, we need to provide care in an ambulatory
setting outside of the hospital. And so this allows the money
to follow the person to seek care wherever he or she needs it.
Ms. DeGette. Has anybody in HHS done modeling on what this
would look like? Have you talked to the insurance companies?
Ms. Norwalk. Yes.
Ms. DeGette. Do you have information you can supplement
your response? What was their response?
Ms. Norwalk. I think that in fact there are people here
today from insurance companies in Louisiana who were very
interested in this proposal.
Ms. DeGette. OK. So people said they would be interested?
Ms. Norwalk. Yes.
Ms. DeGette. And did you get some statistics from them how
much this would cost?
Ms. Norwalk. Again, it is going to depend a lot on the
benefit package and the poverty level and the like.
Ms. DeGette. And you think that should be established by
the State?
Ms. Norwalk. Yes, I think it is appropriate for the State.
Ms. DeGette. And they would have to then apply for waiver?
Ms. Norwalk. Correct.
Ms. DeGette. OK. And so really, the benefits package, the
special needs that people had, chronic long-term needs, so
something like that, that would all be established in your view
by the State and they would come to you with a waiver?
Ms. Norwalk. Correct.
Ms. DeGette. And then would it be guaranteed coverage of
somebody was uninsured or how would that work?
Ms. Norwalk. Again, that is up to the State to determine
whether or not they have guaranteed coverage as I noted
earlier. They may want to keep some DSH funds so that if people
aren't uninsured--so for example, I know one of the issues they
have is a very large migrant population that might not be
covered under State subsidies but may yet be required to be
covered in hospital----
Ms. DeGette. So it is really for them to decide.
Ms. Norwalk. Correct.
Ms. DeGette. So I guess it would be fair to say that this
idea about covering the uninsured with DSH funds rather than in
the other ways we have discussed is from the Secretary's view
more a concept than a plan? Because the plan would have to be
developed by the State and then submitted to the Department for
waivers, correct?
Ms. Norwalk. Yes, that is correct.
Ms. DeGette. OK. Now, Dr. Cerise, what do you think about
all that?
Dr. Cerise. The challenge of moving DSH for insurance which
I think everyone would love to have everyone in your population
insured. If you look at health care spending in Louisiana, in
2004 we spent $19.4 billion. The focus of much of this
conversation is that roughly $600 million of DSH that is in the
public system today, around 3 percent of the health care
spending. We have got 18 percent or so uninsured in the State.
It is not a simple move of DSH funds to insurance, those DSH
funds are buying services today, and if we are going to move
that to insurance, we have got to be comfortable that we are
insuring the critical mass of the population because if you
don't have--when you move them, you are moving them from your
safety net, so you do not have those funds to support your
safety net. And that is the challenge that we are presented
with and in our discussions.
Ms. DeGette. And have you been given any information to
indicate that you could insure those uninsured individuals with
DSH funds while--have you been given any modeling or anything
by that by HHS?
Dr. Cerise. We were given a model in January, the tool that
Ms. Norwalk referred to, that showed that we could insure
319,000 people using existing DSH funds that were dedicated to
the hospitals in the State.
Ms. DeGette. OK. And then how many uninsured do you have?
Dr. Cerise. We have somewhere around 700,000 uninsured in
the State. That is a number of debate but I think that is a
safe number.
Ms. DeGette. So you would be covering somewhat less than
half of the people?
Dr. Cerise. We feel like the 319,000 is an optimistic
projection. I feel comfortable that it would be less than half.
Ms. DeGette. And what would happen to the hospitals and
other facilities that that DSH money is going to? Would that be
all the DSH money?
Dr. Cerise. The remaining DSH funds that we pulled aside
earlier in the discussion were for three groups, one, the rural
hospitals. Here is about $85 million that funds care in rural
hospitals, the State psychiatric hospitals, which is about $100
million, and then $80 million for GME, that actually funds GME.
But the remainder of those care dollars would be moved, and so
those would not be available for those systems to take care----
Ms. DeGette. And the money that would stay, would that be
sufficient in the State's view to preserve those programs,
those DSH programs?
Dr. Cerise. No.
Ms. DeGette. OK. And what would happen to the other 400,000
roughly who didn't get covered with the DSH money?
Dr. Cerise. There would be no organized system of care
funded for the remaining uninsured. They could get a hospital-
based services. They could show up in the emergency room and
hospitals have to take care of those people. They are not
funded to take care of them, but they would have to be seen but
there would be no coordinated outpatient----
Ms. DeGette. There would be no funding for it. Now, what
about under that modeling that was given to you by HHS. What
would happen about a teaching hospital?
Dr. Cerise. Well, we did carve out the DSH funds for GME
and so there are funds that would be either supplanted, if
those programs were moved to other hospitals and those costs
would end up covered through Medicare or some other mechanism.
That is a whole other discussion, but the hospital, for
example, LSU Shreveport Hospital relies very heavily on those
DSH funds, not only for GME but for service delivery, and they
would have real problems.
Ms. DeGette. That would be gone. So would it be fair to
characterize the State's position to the Secretary's proposal
as something that you don't think would be workable for
Louisiana?
Dr. Cerise. That is correct. Without substantial additional
funds, that swap does not work for us.
Ms. DeGette. Do you have any ballpark figure how many
additional funds?
Dr. Cerise. I think--we have done a lot of modeling. I
would say it is north of a billion dollars.
Ms. DeGette. A billion dollars?
Dr. Cerise. A billion for the whole State.
Ms. DeGette. That would be per year, right?
Dr. Cerise. Correct.
Ms. DeGette. Now, this is why we are having this hearing,
so we can bring everyone in.
Ms. Norwalk. The PriceWaterhouseCooper's report says that
40 percent of the uninsured in Louisiana have over 200 percent
of the poverty level. So not all the 700,000 would have
qualified in any event under the report. Now, I haven't seen
the latest statistics from the census bureau that looks at
that, but that is the first point I wanted to make. The second
point is if you assume that you don't have a medical home
system of care and instead are getting treatment in an
emergency department or a hospital outpatient department, it
absolutely is more expensive.
Ms. DeGette. Well, let me just stop you real quick because
this 200 percent of poverty level, we were talking to actually
a lady from my district last week under our S-CHIP hearings and
the problem we have is a lot of uninsured that Dr. Cerise is
talking about who will get treated anyway at the emergency
rooms are as you say people over 200 percent of poverty level.
They are the working poor, and they cannot afford to buy
insurance. So I guess what his point would be that, OK, sure
you are going to insure people who are under 200 percent of
poverty level through this proposal, but they are still going
to be whole bunches of people who don't have insurance, who
can't buy insurance out of their pockets, and they are going to
be showing up at the doors of these emergency rooms. So where
do we pay for that?
Ms. Norwalk. Well, there are a number of things that the
State could do, like a sliding scale for example of care. So if
they wanted to provide subsidies on a sliding scale, that is
one way that they could structure it. Moving care from the
hospital outpatient department and the emergency department
into a medical home system, which is part of the Collaborative
approach, also I think would save a lot of money.
Finally, the concern is from an LSU system, there is at
least $160 million on the table because LSU only has 10 percent
of their patients in Medicare, at least traditionally they did
before pre-Katrina. There is a lot of Medicare DSH and Medicare
GME dollars that aren't being spent because of the patient mix
that was at the LSU system pre-Katrina. If they built a new
hospital for example, I think their patient mix would change
and the number of beds they have for the uninsured in Medicaid
would also change, consequently the entire system. Those funds
I would imagine would need to move around in any event because
of the changing nature of how the system prepares----
Ms. DeGette. Well, let me say my time has well expired. I
appreciate the comity of the Chair. I think it is urgent that
we continue these talks between the State and Federal
Government, and I think that the State needs to work on trying
to put together some kind of a system and submitting the
waivers. But I also think, and the chairman said, he is willing
to bring the Secretary in here. I think that the Department
needs to look much more broadly because the State doesn't think
this is going to work, and I don't think the economies are real
great.
So anyway, thank you, Mr. Chairman, for your comity.
Mr. Stupak. I thank the gentle lady. Mrs. Blackburn,
questions?
Mrs. Blackburn. Thank you, Mr. Chairman. Dr. Stephens, I
want to start with you. I have got this March 3 article from
the Times-Picayune which basically says the hold-up that Mr.
Smithburg talked about earlier is due to a problem between the
city council and the Mayor and getting the approval for these
mobile clinics. And it is absolutely beyond me how you can have
the situation that you have. You are depending on as Mr.
Smithburg put it earlier, the kindness of his brethren at the
table to help care for those that are in need of health care
and you cannot get this approved.
Now, is the city willing to allow these mobile clinics--
they have been there for 7 or 8 months waiting to be used to
relieve some of the pressure that is there. Are you willing to
see that through to completion immediately?
Dr. Stephens. Yes. Thank you. A couple of things, one, the
one problem we had is that they were placed in a residential
area. A solution would have been to place it in an area that
was zoned commercial.
Mrs. Blackburn. That is not what I asked. Are you willing
to see it through to get a solution immediately? You need it to
where people can get to the health care and stubbornness is not
going to solve the problem, hesitation is not going to solve
the problem. Action is going to solve the problem. Being an
outsider looking in, knowing that there is a tremendous amount
of money and you were sitting in the room when I listed the
money that has been sent, the money that has been spent. How
can you not resolve this issue when you have a solution sitting
there for 7 or eight 8 and you have chosen not to act on it?
Dr. Stephens. First thing, the city council did pass the
ordinance to give a waiver so that they can move forward with
the project. And No. 2 as I mentioned earlier is that the
residential area was a problem and not the commercial area.
They had adjacent commercial areas that they could have placed
them. And number three, they could have restricted only to kids
at the schools, and that could have been open today if it was
only to be used by the kids on schools.
Mrs. Blackburn. Dr. Stephens, sounds like some excuse-
making and I think it would be helpful to see some action on
that immediately and not just at some point in the coming
months. I think it would be difficult if they sat there for a
full year without being utilized and without being used.
Dr. Cerise, I would like to come to you with a couple of
questions if I may, please. I want to go back to Dr. Fontenot.
I asked her about the permitting and the licensing on these
hospitals and what we had found when we were there in New
Orleans and some questions that came from that. With your
generators and your emergency supplies, being in the basement
we found out that there were evacuation plans but there was no
implementation plan for those and just--it seemed to be a lot
of blame going around and it was Dr. Guidry who had given us
that information. What is your association--how do you work
with him?
Dr. Cerise. He is in my office. He is a State Health
officer.
Mrs. Blackburn. OK. Great. Are you still permitting these
hospitals--we just heard that switchgear is still in the
basement but there is some kind of system of walling them off.
You want to--we are coming up on hurricane season soon again.
What are you doing to say if we have a difficult situation, how
do we get ourselves out of this? So just a couple of seconds on
that.
Dr. Cerise. Right. There are two pieces, one is how to
mitigate and the other one is with the planning, is to make--if
we get in a situation--we have worked very cooperatively with
HHS and they have provided a lot of assistance in going to
individual facilities, hospitals, nursing facilities to look at
who is able to evacuate, how you would evacuate, what the
capacity is, what Federal assistance we would need. And so we
do have very detailed plans of which each facility's capacity
would be.
Second, on the mitigation piece, we have a group that has
recently completed its work, extensive surveying, of hospitals
and nursing homes to develop building code issues, and that
will tie in evacuation plans. If you have certain things in
place in certain areas, your plan would be to leave or you
would shelter in place.
Mrs. Blackburn. Do you have an implementation strategy so
that you can move people? This time around, do you have that?
Last time around you did not.
Dr. Cerise. Yes, we do.
Mrs. Blackburn. You do?
Dr. Cerise. Yes, ma'am.
Mrs. Blackburn. Excellent. I want to go to the insurance
issue and the 1115 waiver because there is a lot of talk about
that, and you all have a State mandate for health care access
to all Louisianans, and my question to you on this 1115 waiver,
are you looking at Arizona and Tennessee and some of the other
States that have had an 1115 waiver and looking at the lessons
learned?
Dr. Cerise. We are aware of things that other States have
done in order to cover more people, be able to reallocate
funds, to not only pick up the full freight but to share costs
with employers and individuals. I am not sure if that is what
you are referring to.
Mrs. Blackburn. I am asking if you are looking at those
States, their program, their implementation, their delivery
systems and seeing the mistakes that are there and viewing
those as lessons learned and asking them for best practices.
Dr. Cerise. We are aware of some of the problems that
Tennessee had with the large move to a coverage model from an
access model with DSH funds. It is one of the reasons that--
honestly, we are being very careful about the assumptions going
into this, and the reason we have been hesitant to accept, for
instance, a per member per month of $157 for childless adults
as a way to insure people because if those estimates are wrong,
the State is going to be on the line for providing that
coverage with State funds if we don't get an amendment to the
waiver from CMS.
Mrs. Blackburn. And you all are already spending just under
30 percent of your State budget on health care, is that not
correct?
Dr. Cerise. That is probably about right.
Mrs. Blackburn. Are you looking at anything like refundable
tax credits or new insurance products or health reimbursement
accounts, health savings accounts, thing of that nature to put
that into your mix?
Dr. Cerise. The short answer is for this particular
initiative, we have looked at the ability to provide an
insurance product for people with existing funds. We have not
gotten into the details of what that would be.
Mrs. Blackburn. OK. And one more quick question. You have
gotten $15 million on the workforce recruitment money, but you
think it is going to take $120 million to rebuild your
workforce, is that correct?
Dr. Cerise. That is correct.
Mrs. Blackburn. All right. Thank you. I will yield back,
Mr. Chairman.
Mr. Stupak. I thank the gentle lady from Tennessee. Mr.
Melancon for 10 minutes questions, please.
Mr. Melancon. Thank you, Mr. Chairman. Ms. Norwalk, let me
ask--maybe this is the dumbest question I am going to ask, but
we are 18 months out since the storm's occurrence. Why are we
here today? Isn't the Department of Health and Hospitals able
to work with the States to try and provide health care to work
through the problems? Why does the Congress have to bring a
Department here and all these people from Louisiana here to try
and solve what should have been solved by the Agencies
themselves.
Ms. Norwalk. We certainly have been working very diligently
to make sure that health care is being provided in the area. I
think the needs have--the short-term needs, we have continued
to work with them. They continue to be exacerbated as
populations return, as the populations change. For example, the
number of migrant workers that are coming into the area often
do not have health insurance and may have workers' comp issues.
Mr. Melancon. And that is correct because we haven't done a
thing. We haven't taken any incremental steps forward. We are
worrying about the Charity Hospital and the big building that
everybody doesn't want. That is what we are worried about. We
are not worried about the teaching facilities for the State of
Louisiana, we are not worried about the hospitals in the public
sector--private sector going broke, we are not worried about
people that we have to give health care to, we are worried
about the politics of some building in south Louisiana. The
State Collaborative. How many weeks was it between the time--
maybe Dr. Cerise--between the time that you all submitted it to
the Feds, then they started talking to you again. It was about
a 6-week period or was it longer than that?
Dr. Cerise. We submitted it October 20. We had regular
discussions for--beginning early November until mid-December,
and then there was a 6-week gap before the proposal or the tool
was presented to us by CMS.
Mr. Melancon. Well, if I remember correctly, it was a
concept paper for a redesigned health care system for region 1
for a CMS submittal. Prior to a statewide rollout, the State
will assess the benefits of the current rural safety net
comprised by merely small rural hospitals and the rural health
clinics. One of the most important consideration, present
implementing the new system of care, its affect on rural
communities. Local rural communities face many unique
challenges which have not often been addressed in the
Collaborative process, as region 1 is primarily an urban area.
These challenges include significant shortages of health care
professionals. The role of rural hospitals is critical safety-
net providers and limited financial resources.
Now, they brought you a rock and then 6 weeks later, after
they brought you the rock that you asked them to bring, you
tell them that is not the rock you want to take it back and
start over again. So where we are now at month 18 is they don't
want to continue filling out application forms that you are
going to tell them you are not going to accept?
Ms. Norwalk. I actually would characterize it differently.
I have a log of all the contacts we had since November say
through February, and there were significant conversations long
even after they submitted the proposal after October 20.
Mr. Melancon. Why were you all silent for 6 weeks?
Ms. Norwalk. We weren't silent for 6 weeks. That is my
point. We were silent the week of Christmas and for a few days
after New Year's. That is true. I apologize. I am sure people
were on vacation. So other than that vacation schedule, I
have--I can tell you calls that were made, e-mails that were
sent back and forth about financial modeling, about all sorts
of issues that relate to this, and we have been----
Mr. Melancon. Thank you. Dr. Cerise.
Dr. Cerise. We had regular staff calls throughout the month
of November and until mid-December. We had no staff calls
working through budget neutrality, these technical pieces that
we have to work through. CMS cancelled the call the week after
my visit to your office, December 12. That next call was
cancelled, and the next information I would get on this would
be from the Secretary's office, and that is true, I got that.
But it was in January and it was the night before a very public
release of this tool.
Mr. Melancon. Was that when we had the----
Dr. Cerise. It was not a discussion point at that point.
Mr. Melancon. Is that when we had the Irish kilts playing
music with your announcement in New Orleans?
Dr. Cerise. No, that was the beginning of the process.
Mr. Melancon. That was just another pie in the sky. We have
heard from the hospitals earlier that they had only gotten a
portion of their cost for uncompensated care from the State.
What can you tell me about that element of the Collaborative?
Dr. Cerise. The uncompensated care is one piece of the
hospitals' problems right now. It is an important piece. But as
you have heard, they have got a number of other issues. The DRA
provided funds for uncompensated care for a period immediately
after the hurricanes. There was about $134 million allocated
for that, about $100 million of that went to hospitals. For the
remainder of that fiscal year--and that was time-limited. It
expired at the end of January 2006. Between February and July
2006, the remainder of the State fiscal year, the State
appropriated $52 million in uncompensated care for hospitals in
the region. This current fiscal year of 2006, there was $120
million in uncompensated care appropriated to the hospitals
that don't normally get this appropriation but it was in
recognition of the fact that the care had shifted from Charity
Hospital. $120 million was a number that we and the Governor
decided upon because our calculations thought it would be an
amount appropriate to cover the full costs of the uncompensated
care in the impacted region. It turns out through discussions
with the Hospital Association, they preferred to spread those
dollars to other parts of the State as well. There was less
available for the New Orleans region, and based on the formula
that was put into the Appropriations Act, we don't expect to
expend the entire $120 million. I have been in discussions with
some of the hospitals with the division of the administration,
looking at how we might go back to do that, but I want to be
clear because there has been a lot of discussion about these
dollars not flowing. There have been uncompensated care dollars
going to--it has been the State's intention--when we discussed
this $120 million with the Hospital Association during the
appropriations process, it was our preference to concentrate
those dollars in the New Orleans area and cover full what we
put forward was 90 percent first dollar uncompensated care
costs for all hospitals in the impacted region, which is a
different formula.
Nonetheless, when the existing formula that is in the
appropriations bill, we expect there will be money left over
and are committed to going and looking at how to do that. We
just made the first half-year payment on this, and the way this
works is you have got to show the cost to be able to get the
reimbursement. And based on that first half-year payment, we
expect that the entire pool will not be spent.
Mr. Melancon. Thank you. Where I am right now, and Ms.
Norwalk, I know this is just something you have got to do as
part of your job today, but I am living this down in south
Louisiana. There are other people down there. They are tired.
They are frustrated. And if we can't get this government to
work for them, then we need to find some people that will. And
I am not yelling at you, I am yelling at your Department,
please. You know, there has been so much going back and forth,
finger-pointing at each other, and nothing getting done. And it
started the day after the storm when the Governor of Louisiana
was told she didn't ask for the right things from the Federal
Government. And it has gone downhill ever since.
I didn't think, and having worked previously in State
government and worked with the Federal agencies--usually those
people that worked in those departments were there to help
guide us and give us assistance and tell us what I's to dot and
what T's to cross and how to make it work and not put a stone
wall up and try and make us climb over it every time or change
the rules every time we came.
So I would ask you to go back to Mr. Leavitt and tell him
that this committee is meeting because his agency has not
performed the duties and responsibilities they were charged
with. And I am going to ask the chairman, you have asked for
the records. I would like to have every detailed record, phone
calls, e-mails, the whole works. And if we got to spin them, we
spin them. If the people of Louisiana are wrong, then we are
going to prove them wrong. If the Heath Department is wrong,
then we are going to prove them wrong. But I am not going to
continue having hearings at infinitum when the people in the
Gulf Coast of this country are suffering as they are.
Now, I would like to ask one last question. During the
issues with the Collaborative, during the issues with the going
back and forth, during your testimony and the drafting of your
testimony today, was there any member of our delegation that
may have had input or made phone calls on a regular basis, his
office or others, about what was going on and what the
Department----
Ms. Norwalk. In my testimony?
Mr. Melancon. No, from your Department from someone in our
delegation?
Ms. Norwalk. No one influenced my testimony.
Mr. Melancon. That is influenced. I asked you if you have
had any contacts with people within the Congress that are----
Ms. Norwalk. I personally have not. Whether or not--there
may have been contacts within the Department. I really have no
idea. But my own testimony was testimony that we wrote, and as
far as I know, no one influenced my written or oral testimony
in any way, shape, or form that was not within CMS.
Mr. Melancon. Thank you. I would ask you if you would ask
the people that you work with in the Department. Thank you, Mr.
Chairman. I yield back.
Mr. Stupak. Thank you, Mr. Melancon. Dr. Burgess, 10
minutes.
Mr. Burgess. Thank you, Mr. Chairman. It has been a long
day, I have heard a lot of stuff. I will address Mr. Melancon's
soliloquy when I get to the end of my questioning. But there
are a few things I still want to try to drill down on.
Ms. Norwalk, in HHS, there is a proposed rule CMS 2258-P.
It is my understanding the goal of this regulation would be to
allow the money to follow the patient. We have heard that
several times today that that is a goal that several people
have said that they share. And allow the money to be received
by the health care provider without having to stop at the State
capital. Can you tell us what the status is of this proposal
and when it might become effective?
Ms. Norwalk. Well, the rule you are referring to is the
rule on certified public expenditures and/or Medicaid. It is
currently out of proposed form. The comment period closes next
Monday, March 19. It will take us inevitably some time to go
through these quite voluminous number of comments we have,
particularly from public hospitals and States around the
country and other providers that are concerned about this. We
will go through those. Once we put out a finalized rule, it
will effective 60 days after it is published. I don't know the
timing because I would hate to guess----
Mr. Burgess. OK, so this is not just for Louisiana then?
Ms. Norwalk. That is correct.
Mr. Burgess. Was there any sort of special rule or special
designation because of the Gulf Coast area being so harshly
stricken?
Ms. Norwalk. No, we actually have been working with
Louisiana on these related issues to DSH funds and certified
public expenditures, making sure that the States have access--
the public hospitals have access to the funds that they should
receive through, say, DSH for example and other governmental
transfers.
Mr. Burgess. Well, Mr. Melancon's concern--forgive me for
interrupting but I am going to run out of time and we are going
to be kicked out of here. But Mr. Melancon is concerned about
the length of time that it takes for money that is generated
here to get to where it is needed, and I sympathize with that.
I probably have a different perspective than him. I do think
that there is a hold up and it may well be the State capital;
and if that is the case, can we eliminate that from the chain?
Can we just remove that as an obstacle, or is there legislative
language that you need from us to remove that obstacle going
forward? We are 18 months into this. Heaven help us if we are
another 18 months into it and we are still having these same
arguments.
Ms. Norwalk. No, the overall issue is in fact a statutory
issue, so inasmuch as--because Medicaid is a State-Federal
partnership, those funds do flow through the State. I don't
believe there is a way that we could change that without
statutory change, but we will have to ask our counsels.
Mr. Burgess. And what about the DSH funds that we have
heard so much about today?
Ms. Norwalk. A lot of the DSH funds again flow through the
State.
Mr. Burgess. Can we make that not happen?
Ms. Norwalk. No, I will have to go back to counsel's office
but I don't think that we could do that without a statutory
change. Not to say that we couldn't change the allocation of
how those funds are--but even so, they would run through the
State.
Mr. Burgess. But we have heard from 13 or 14 fine
individuals here today who all have good ideas on how to spend
the money, and if the problem is that wherever the roadblock
is, if we can eliminate one stop to get the money to these fine
individuals to get them up and working and get them up and
running, I think we should do that.
Dr. Cerise, let me ask you about the suggestion that
Louisiana expand its capability for dealing with uncompensated
care. So what do you think can be done on the Federal level to
expand the--make those Federal dollars that we generate here,
make them more available to the practitioners on the ground?
Dr. Cerise. Well, for the DSH component, it is a State-
Federal partnership. There is a State share. The State has to
put up its share to draw down the Federal funds and----
Mr. Burgess. Let me interrupt you then because we heard
from Mr. Smithburg. He said when he was in Texas, he could get
a provider paid but under his current regime he can't because
those DSH funds are prohibited from going to providers as
opposed to institutions.
Dr. Cerise. I think what he was referring to was the fact
that--two things, one, those funds have to go through a
hospital, a hospital that is eligible to receive
disproportionate share funds. Those funds then, they can fund
clinic activity and--but they have to go through the hospital
first. And that hospital is not eligible to get physician cost
reimbursed with the----
Mr. Burgess. All right. Well, what do you need to make that
happen? Dr. Quinlan was here and testified for us. What do you
need for us to be able to just write the check to Dr. Quinlan?
Dr. Cerise. I probably have a different answer than Leslie.
We think it is just interpretation of DSH statute. In fact, we
have a--there is a fifth circuit decision in Louisiana dealing
with rural hospitals that says that those costs are allowable
for physicians, but the Department's position has been that
those costs are not allowable for the State.
Mr. Burgess. Yes, well, we did hear that testimony, that
the hospital in the parish next to Jefferson Parish was a
critical access hospital and would fit that criteria. I would
suggest--there probably is something you can do, either at the
State level or at the HHS level and for heaven's sakes, let us
get that done so we don't continue to be up here and have to
beat each other over the head about this stuff.
Now, Ms. Norwalk, did you have some staff members in Baton
Rouge to help with this process that we heard about, the
Collaborative process?
Ms. Norwalk. We did have someone there through the end of
February and we have had people go down periodically. The
Secretary has been down eight times, I have been down, I don't
know, half-a-dozen times, a number of staff people go down a
number of times a month in order to help facilitate
communications between the State and the Federal Government, as
well as dealing with some of the issues that we have seen in
other regions. We had someone on the ground full time dealing
with health care provider issues. He has since gone back to the
regional office of Texas, so it really depends on the timing,
but yes, we have had people in Baton Rouge and New Orleans.
Mr. Burgess. Well, has that full-time staffer, has that
been helpful to have that person on the ground?
Ms. Norwalk. I heard many accolades from health care
providers who found it very useful to make sure whatever
certification issues they might have or other problems they
might have in dealing with the Department on a more regular
basis could help make sure that we could speed up the access to
clinics that were brand new, for example, or whatever--there is
one in St. Bernard's parish I believe that we helped facilitate
that getting paid as quickly as possible, filling out the forms
and any--walking those providers through whatever processes
were required so that people could get the care they needed as
quickly as possible.
Mr. Burgess. So are you going to continue that, to keep
that staff available?
Ms. Norwalk. Well, they are absolutely available to go back
to the region as is necessary.
Mr. Burgess. It sounds like it is necessary. Dr. Cerise,
have you found having a full-time HHS staff there has been
helpful?
Dr. Cerise. There have certainly been some issues that they
have been able to facilitate, no question about it. The
fundamental issues I think here this committee is raising are
not the kind, at the level, that would be addressed by the
people on the ground.
Mr. Burgess. I don't know. I would disagree. I would think
any help, any help at all, that you could get would be
beneficial. Again, we have heard from 13 or 14 wonderful
American heroes today and the difficulty they have jut doing
the most basic parts of their job. And that is troubling to me.
Dr. Stephens, before I get too wrapped up in this, let me
just ask you, because you made the statement that the New
Orleans Health Department will have to rebuild. Now, the
responsibility for rebuilding the New Orleans Health
Department, is that our responsibility at the Federal level, is
that Ms. Norwalk's responsibility, Dr. Cerise's responsibility,
Mayor Nagin's responsibility? Whose responsibility is that to
rebuild the New Orleans Health Department?
Dr. Stephens. I think it is all the above.
Mr. Burgess. Dr. Stephens, with that, I am running out of
time. With all due respect, as you know, if you got too many
bosses, no one is in charge. I would submit that you better
take responsibility for that. Tell us what you need from us,
but please take the leadership on that and get that done. Mrs.
Blackburn referenced the primary care trailers that were up and
ready to go but required a city ordinance to--that should not
be hard. Let us do that. Mr. Melancon waxed eloquently about
the failures to the extent that they rest with the Federal
agency. I suspect the Federal agency is willing to take
responsibility for that. At the same time, they are hardly the
only persons involved in this; and my personal opinion,
although I do not have the facts to back it up, but my personal
opinion is there is a big logjam at the State level, and I
would suggest to this committee that we do everything we can to
get those dollars to the hands of the people who are going to
provide the care and take care of the sick people in New
Orleans, Louisiana, and let that bypass Baton Rouge if it has
to happen. I frankly do not understand, yes, we should hold a
Federal agency accountable and we should hold DHH accountable,
but for the life of me, not one single elected official who has
stood for re-election since this hurricane, has been turned out
of office. And I find that frankly astounding. It just defies
belief with the amount of problems that you have had, yes, I
think you need to hold some people accountable and I think
those people you need to hold accountable are your elected
officials. That is only way something is going to happen, and I
really make those comments to the 13 or 14 people who testified
earlier because again, I just cannot tell you of the personal
pain it has caused me to be unable to get this situation any
better than what we find it today.
Thank you, Mr. Chairman. I will yield back.
Mr. Stupak. Thank you, Mr. Burgess. OK. That just about
concludes our hearing today. We have come up with several
issues that can--I think believe can be addressed between the
State, Federal, and local governments, and I ask you all to go
back in the next couple of weeks and try to work on them.
This committee will follow up with each and every one of
you to insure that the commitments that are made are going to
be kept. As I said earlier, this will be the first of many
hearings that we are going to handle, and we want to get back
to you for a progress report, and I promise you, we are going
to keep the subcommittee moving forward.
Ms. Norwalk, I mentioned to you about the CMS and Dr.
Wiltz's application. It is not CMS, it is HRSA.
Ms. Norwalk. Thank you.
Mr. Stupak. So who is the person in HRSA?
Ms. Norwalk. Betty Duke is the administrator of HRSA.
Mr. Stupak. Betty Duke?
Ms. Norwalk. I am more than happy to bring that back to
her.
Mr. Stupak. Please do because she will be getting an invite
from us to appear before the committee, along with Mr. Dennis
Smith on the Collaborative plan. And Dr. Lynch, we still want
to hear more about the VA and Big Charity's goal there, so we
may ask you to come back. Unfortunately with the limited time
and as you can see we are being pushed out of here, so we are
going to have to clear here quite quickly. I want to thank each
and every one of you for coming.
Mr. Melancon, you had one more thing?
Mr. Melancon. Ms. Norwalk, I need to apologize to you. I am
a little rough today. I don't think it was your department that
has the problem with the delegation. Mr. Lynch, would you look
into what is going on with the VA LSU statements and let me
know if there is anybody that is in there manipulating the
statements or trying to manipulate the deal? It is my
understanding that the VA is saying now they are going to pull
out of the deal with LSU, and I think there is--that might be a
basis for another good hearing.
Mr. Burgess. Mr. Chairman, if I may, I would just say that
I would welcome some input from the Louisiana delegation into
this process. I think it is necessary.
Mr. Melancon. Yes, I have been looking for them, too.
Mr. Stupak. OK. The record is going to be open for 30 days.
Mr. Stephens, thank you for moving those trailers. Dr. Cerise,
thank you for looking at the nurses. Let us keep moving in a
positive direction. We got two down and only 2,000 more to go.
Thank you all.
[Whereupon, at 4:25 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
Testimony of Bryan Bertucci, M.D.
My name is Dr. Bryan Bertucci. I am a Family Physician and
Coroner of St. Bernard Parish. Medicine is not well in St.
Bernard. 100 percent of our homes, offices and buildings were
destroyed and for the first time in history FEMA declared a
parish or county 100 percent destroyed. 154 St. Bernard
residents died in Hurricane Katrina.
St. Bernard was flooded twice by Hurricanes Katrina and
Rita, experienced an oil spill, liquid mud, mold, snakes,
flies, mosquitoes, piles of trash, mice and rats. St. Bernard
is a very difficult place to live and despite that our
residents continue to return.
Our biggest hindrance is the overwhelming lack of medical
facilities. Our 194 bed hospital is gone. Of 150 physicians
only 6 remain. Only 10 registered nurses remain. To see certain
specialists residents are often required to travel 30-60 miles.
We encountered one financial roadblock after another as we
attempted to rebuild. Because Chalmette Medical Center was a
fee for service hospital we received no funds. We were
penalized for being privatized. Because we were not on the
parish budget we received none of the Community Block Grant
monies. We were penalized for being independent. The Stafford
Act prevented FEMA form assisting with physician and nurses
salaries. The parish received $621 million of Community Block
Grant money for infrastructure repairs--medicine received none.
Perhaps our biggest problem is that Federal and often State
officials do not realize that St. Bernard Parish is not part of
Orleans. Funds given to Orleans Parish stay in Orleans Parish.
Medicine has metamorphisized itself from DMAT teams, to
Public Health, to our present 22,000 sq. ft. temporary trailer.
We see 100-120 patients a day. The severity of the illnesses in
our patients is similar to those seen in a small ER or Urgent
care. We I&D abscesses, suture lacerations, stabilize MI and
congestive heart failure patients, and give IV fluids and
antibiotics. Almost a quarter of these patients have no
insurance coverage and are ``self pay'' or ``no pay''.
A foundation is willing to donate 30 acres of land eight
feet higher than the land Chalmette Medical Center was located
on. We would like to thank the Franciscan Missionaries of Our
Lady Health System, Mobile Oil Refinery, and Social Service
Block Grant have donated funds but this is not adequate
Mental Health is in crisis with 50-60 percent of adults and
20-30 percent of children depressed, drug overdoses on the
rise, and the chronically ill psychotics and schizophrenics are
decompensating due to lack adequate counselors, psychiatrists,
and psych beds. Charity Hospital Crisis Intervention Unit
destroyed.
St. Bernard lacking significant emergency room services has
to ship patients 18-35 miles for emergency care .Our parish is
surrounded by water and our limited number of ambulances has to
cross bridges, railroad tracks, and circumnavigate traffic jams
depending on the time of day. An ambulance ride can vary from
15 minutes to an hour depending on delays encountered. A
routine ER wait is 4-8 hours. These patients are occasionally
housed in ambulances making vehicles unavailable for hours.
The logical solution for St Bernard Parish is a medical
village consisting of a permanent physician office building,
out patient surgery center, and out patient diagnostic center
and eventual hospital.
This medical village will assure the resurrection of
Primary Care Physicians and subsequent return of our
Specialists. It will decrease number of our residents needed to
be transferred to hospital ER's as we can treat them locally
and free up our Ambulances. It will allow our Elderly to return
as Nursing Homes, Homes for Assisted Living are built. Some
elderly will rebuild their Homes. It will supply Jobs as the
former hospital was one of the largest employers in the parish.
Could provide Psych Beds as our former hospital had 24 psych
beds prior to Katrina. With a hospital and medical facilities
we can begin work on Electronic Medical Records and Medical
Homes.
To make these dreams a reality we need three things.
1. Bridge Money--as soon as possible
A. Social Service Block Grant Money
we need an extension on funds we were allocated
due to expire July, 31-2007
make more SSBG funds available to medicine in our
area for infrastructure.
B. Community Block Grant Funds--since we have a non profit
group now, we need to make funds available to build permanent
medical structures to replace our present trailer.
C. Rural Designation for St. Bernard--for Medicaid and
Medicare patients to help offset costs of treating indigent
patients for hospitals and physicians.
2. Medical Village--need money for brick and mortar. Once
our out patients facilities are built it will allow access to
quality medical care while our hospital is being built.
3 Hospital--the ultimate cure. We have over 25,000
residents. As our elderly return and others receive the ever
evasive ROAD Home money to rebuild we will approach the 35,000
we need to support a 40-60 bed hospital. Since it will take 18-
24 months to build a hospital we need to begin. Now.
If funds are available I ask that they be earmarked for St.
Bernard Village and Hospital Specifically and not to the State
or local funding pools as we continue to find them
inaccessible.
I have refused to wear a white coat again until medicine in
St. Bernard is whole again. To wear a white coat would be like
waving a white flag and surrendering to the unacceptable
situation that presently exists in medical care.
Thank you for allowing me to voice our Parish dilemma to
such a knowledgeable, distinguished, and concerned group. Thank
you for listening.
----------
Testimony of Karen B. DeSalvo, M.D.
Mr. Chairman and members of the subcommittee: Thank you
for the opportunity to speak today about post-Hurricane Katrina
health care recovery in New Orleans.
I am Dr. Karen DeSalvo, the Executive Director of the
Tulane University Community Health Center at Covenant House, a
clinic formed in the aftermath of the storm to meet the urgent
needs of the population of city. Since September 2005, I have
been active in efforts to restore immediate health care
services and in planning groups focused on the longer term
vision of a redesigned health system.
Before I begin my testimony, I want to thank all the
members of the committee for the opportunity to review the
progress we have made. Health care is not a partisan topic and
many have contributed to our progress, including the city,
State and Federal officials you will speak with later. All
deserve recognition for working earnestly towards resolution of
a uniquely difficult situation for our nation. Your assistance
is needed now to help health care recovery efforts in New
Orleans continue to progress so that people who are currently
uninsured, and without access to essential primary and
preventive care receive the care they need.
Today I will share with you my perspective as a primary
care physician trying to care for the uninsured patients on our
city. I hope to give you a snapshot of what it is like to
practice medicine in that environment, the challenges we face,
what would help improve access to care in the short run, and
how we might go forward to ensure that we provide support for
the New Orleans safety-net primary care system while deciding
the larger policy issues.
II. Primary Care Recovery: What We Have Accomplished
We have come a long way towards restoring health care
services in the 18 months since the flood waters receded. Much
has been made of the divisions in New Orleans, of our struggles
in surviving the storm and its aftermath, and in beginning the
process of rebuilding from it. A much overlooked bright spot in
those efforts has been the progress we have made as a community
in building a care network for our most vulnerable citizens.
The community has pulled together in unprecedented ways to
overcome overwhelming challenges to restore services and define
a better health system.
We described this Louisiana vision for our re-engineered
health system through the reports of several planning groups.
Health and Human Services provided critical support for much of
this work beginning with the United States Public Health
Service support of the ``Framework for a Healthier New
Orleans'' and culminating in the Louisiana Health Care Redesign
Collaborative Concept Paper (Concept Paper). While we have been
planning the future, we have been living in the present, all
the while trying to keep within the vision of a distributed
ambulatory care system that can make primary care more
accessible.
Historically, our safety-net system has been the Charity
hospital and associated clinics which were staffed by
physicians from both Louisiana State University and Tulane
University. An estimated 250,000 people received care,
including primary care, through that system. Before the storms,
smaller, community-based providers were increasingly working in
concert with the Charity system, but their share of safety-net
care provision was small.
The flooding caused by Hurricane Katrina destroyed much of
the bricks and mortar of the safety-net system in New Orleans
and the surrounding area. Affected institutions included the
Charity system and all other safety-net providers. Even though
we had a successful evacuation of New Orleans, many of the
sickest and poorest patients remained behind and needed care.
These people were those being pulled out of flood homes where
they had been for many days without access to their medications
or health care. First responders and others coming to
reconstitute our city were also in need of care.
In response to that need, Tulane University resident
physicians came to New Orleans in the second week of September
2005 when the waters in most of the city had receded and there
were dry places to set up temporary care sites. These
physicians-in-training partnered with the police to establish
first aid stations and provide general primary care at 6
makeshift sites around town. Most of these clinics were started
with meager provisions: a willing physician, a stethoscope, and
a few donated, portable supplies. The providers generally
worked without power, potable water, or sanitary systems. Some
of these health sites were on the sidewalk under tents, some in
hotel ballrooms, and others in police station dispatch rooms.
In addition to providing much needed care for patients,
these makeshift operations stimulated a culture change in our
primary care community. As academic physicians working at
Charity, we had provided a major portion of the safety net care
for the city through the Charity Hospital based clinics. For
those patients who could get an appointment with us, the
quality was good. However, we also knew that 12 month waiting
periods for new patients to get in to see us, and the lack of
sufficient after hours access was preventing us from reaching
many.
Creating primary health care from scratch in the post-
Katrina environment, gave us first hand experience with a new
paradigm of care and an unexpected opportunity to rebuild a
better system. Included in this health care culture change was
an understanding of the essential role of teams and
partnerships, the synergistic value of collaboration, and the
benefits a multi-disciplinary approach to care. Also included
in this paradigm shift was attention to developing patient-
centered models of care. The makeshift clinics were established
in response to where the patients were. For example, we
identified new sites of care based upon scouting the streets of
recently opened zip codes. We then set up our clinics as near
to the patients as we could. We worked side-by-side with
volunteers from all disciplines. To access care, patients only
had to walk up to the card table and ask to be seen.
Over the course of the ensuing weeks, open tent structures
were replaced by mobile vans and a few clinics landed space in
available buildings such as empty store fronts and dormitories.
Eventually, the restoration of utilities moved us back in to
these more traditional venues which we generally welcomed.
However, we wanted to retain some of the elements of our new
paradigm from our ``street based'' primary care as we moved
ahead.
From a care table to a neighborhood-based medical home:
Tulane Community Health Center at Covenant House
One of the early temporary care sites opened in early
September 2005 when Tulane trainees and faculty set up a card
table as temporary care site on the sidewalk in front of the
community center. At the height of need, we served 150 patients
a day. Desiring to maintain this new neighborhood health
clinic, Tulane partnered with Covenant House and Johnson &
Johnson to develop a permanent neighborhood clinic nested
within a community center (www.tucovenanthealthcenter.org). We
had, by default, become a medical home for many in the city,
particularly those in the neighborhoods near us and were
committed to continuing to that public service.
The Tulane Community Health Center at Covenant House
started as a makeshift, post-Katrina first aid station that
developed into a permanent primary care clinic. Since
transitioning from a card table to a permanent primary care
clinic, we have become a source of primary care for hundreds of
patients and have seen over 12,000 since opening our doors 18
months ago. This medical home is able to provide basic primary
care for adults including care through a multi-disciplinary
health care team. We have access to basic laboratory and
diagnostic studies. We also serve as a training site for house
staff and medical students and other health professionals so
that the next generation of clinicians are exposed to a
patient-centric model of primary care. We have a sophisticated
electronic health record that allows us to manage our
population of patients proactively and provide decision-support
for clinicians to improve the quality and cost-effectiveness of
care.
We developed a fragile patchwork of referral patterns for
laboratory, diagnostic and specialty services. We have a
sophisticated electronic health record that allows us to manage
our population of patients proactively and provide decision-
support for clinicians to improve the cost effectiveness of
care.
To support the ongoing delivery of primary care from
clinic, we have been aggressively seeking funding so that we
can expand our ability to provide health care to this uninsured
population. We have strung together our funding from an array
of entities including the government, corporations, individual
donors, and foreign nations. Specifically, we are supported
through the Social Services Block Grant, foundation support
from the Avon Foundation, Americares, the American Refugee
committee and a generous gift from the People of Qatar.
If we adhere to our budget and expectations, we could
provide basic care to 4200 patients at a cost of $360 per year
per person for the next 3 years. In the near future, we are
implementing business processes to collect reimbursement from
available sources and plan to secure a more stable funding
stream. We may request the subcommittee's support as we move
forward.
The Partnership for Access to Healthcare (PATH): A
Collaborative Prototype for Medical Home System of Care
Though we are focused on meeting the immediate health care
needs of the population we serve, we are also working towards
creating a neighborhood based-medical home that can not only
serve as a potentially replicable model but help to transform
the New Orleans health care system. The concept of a medical
home has been well described by national groups and our
Louisiana Health Care Redesign Collaborative Concept Paper. It
emphasizes health promotion, preventive health and primary
care, supplemented by peer education and support. The health
team is multi-disciplinary and includes social services and
mental health support.
Our clinic is one in a newly developed, broader system of
care that has emerged since the storm to fill a void left when
the traditional safety net was displaced by the flooding. This
network of safety net clinics represent service, called the
Partnership for Access to Health Care (PATH) (www.pathla.org),
represents a broad group of clinics working cooperatively to
provide access to care for the uninsured and under-insured.
These partnerships bring together public and private entities,
academia, consumer groups and corporations into a common goal
of filling the need. In the aggregate, these clinics serve 900
patients a day, an estimated 50,000 covered lives. An estimated
90 percent are uninsured and represent the rich racial, ethnic
and cultural diversity of post-Katrina New Orleans. Inclusion
in the group is open to providers willing to share in the core
values of quality and cost-effectiveness. Current participating
PATH clinical entities include:
Clinical Providers participating in the Partnership for
Access to Healthcare
Algiers Community Health Clinic (New Orleans Health
Department/EXCELth Inc.)
Common Ground Health Clinic St. Cecilia Clinic (Daughters
of Charity Services of New Orleans/EXCELth, Inc.)
DCSNO at Causeway Clinic (Daughters of Charity Services of
New Orleans)
Jefferson Community Health Centers, Inc Marrero (Jefferson
Parish)
Jefferson Community Health Centers, Inc, Avondale
(Jefferson Parish)
University Hospital (Medical Center of Louisiana at New
Orleans)
Hutchinson Clinic (Medical Center of Louisiana at New
Orleans)
Ida Hymel Health Clinic (New Orleans Health Department/
EXCELth, Inc.)
Edna Pilsbury Health Clinic (New Orleans Health Department)
Healthcare for the Homeless (New Orleans Health Department)
McDonough 35 High (New Orleans Health Department)
St. Charles Community Health Center
St. Charles Community Health Center (Lulling)
St. Thomas Community Health CenterTulane Community Health
Center at Covenant House
Tulane University Pediatric Clinic and Adolescent Drop in
Center at Covenant House
New Orleans Science & Math High (LSU HSC Adolescent School
Health Initiative)
Eleanor McMain High (LSU HSC Adolescent School Health
Initiative)
These providers have deliberately set out to create a
distributed system of neighborhood based clinics that will
provide more accessible care for the returning New Orleans
population.
These partners have worked collaboratively to identify and
fill gaps in primary care services, develop the model of the
medical home, and find ways to link their patients into
specialty care and other services. With continued support and
additional resources, PATH could serve as the core of a future
model medical home system of care that could transform medical
care in Louisiana. I88III. Primary Care Delivery: The
Challenges
The primary care community struggling to provide care for
a growing number of uninsured and underinsured individuals
faces many challenges. The health system's ``short term''
needs, which we presumed would be long behind us, continue to
dominate our minds, conversations, and energies. The generous
support of corporations, foundations and citizens has been a
critical bridge, but will be insufficient to rebuild and
sustain the primary care safety-net system.
For our part, the major limitations involved poor access
to specialty care and diagnostic services. On a daily basis,
this means my ability to provide evidence-based care for a
typical patient is limited. For example, we do not have access
to colon cancer screening and diabetes eye care. We also do not
have access to urgent diagnostic studies such as brain imaging
or endoscopy. As a result, we sometimes need to rely on sending
patients to emergency rooms for such tests. Worse, patients
sometimes go without arriving at the hospital with significant
or long term health consequences that prevent him from being a
productive member of our community.
Like many other clinics in the city, we have an
insufficient number of clinical providers at our site. For our
part, if we could have more staff, we have the bricks and
mortar capacity to expand services and hours. However, as you
might imagine, finding physicians and other clinical personnel
willing to move to New Orleans is a challenge. There are
concerns about long term job security and frustrations about
trying to maintain a high standard of practice in a broken
environment. One of my physicians has been so frustrated with
the difficulties of providing basic care for his patients that
he has considered returning to Liberia to practice.
Complicating matters is the high burden of chronic disease
for the uninsured, low literacy and the rapidly expanding
population of Spanish-speaking immigrants. Adoption of best
practices, the use of care management and health information
technology will help with the care of those with chronic
disease. A strong social services infrastructure can help
support those with extensive social service needs. The
immigrant population poses its own unique set of challenges for
us. The low income workers in this group are likely to not be
eligible for coverage if they are undocumented immigrants. We
will eventually also need to leverage existing Federal programs
to care for these populations.
Congress and the Administration can play a major role in
expanding and sustaining access to primary care for our
community. We are still in desperate need of additional
assistance. Our short term problems are largely not those of
bricks and mortar. Instead we are under-resourced and have a
short time window until the existing resources we do have will
end.
IV. Primary Care: The Opportunities and Needs
New Orleans and its surrounding region cannot recover
without adequate health care services. Sufficient
infrastructure and accessibility are essential if we are to
retain and attract business and industry, tourism, and have a
productive workforce. The most cost-effective means of
rebuilding focuses resources on the primary care
infrastructure. A robust system of primary care is also
critical to unclog an overwhelmed hospital system. If we build
a highly functional and accessible system, people will need to
use emergency rooms less. Good primary care prevents hospital
admissions for illnesses such as asthma, heart failure and
diabetes. Patients would be better served prevention, proactive
care management and empowering themselves.
We will continue to seek your help in our ongoing efforts
to revive the primary care services in the city and region. I
understand that Congress faces many issues related to Gulf
Coast recovery, and that spending must be done wisely and with
an eye toward what will offer the greatest benefit to the most
people. Preventing and intervening early in the process of
chronic disease saves money. Nothing is more critical to the
renewal of New Orleans than health care.
There are three ways that the subcommittee can help us
provide immediate access to health care and prevent us from
reverting back to relying on emergency rooms for care.
1. Increase access to primary care in New Orleans for the
uninsured through extending the SSBG deadline and providing
further resources through the Deficit Reduction Act funding
We need to move forward with implementing core components
a medical home system of care model that will provide access to
care immediately to the nearly 180,000 estimated low income
uninsured in our area. The most cost-effective and patient-
centered means for doing this is to support and sustain
existing primary care resources and add new services to fill
gaps until longer term policy decisions can be made.
While our community debates the best way to expand health
insurance coverage for our uninsured population, we need to
support the continued development of the medical homes and a
supportive delivery system of care. This is essential to ensure
continued progress rather than returning to a reliance on
emergency rooms for care. The PATH network has all the makings
of a medical home system of care but it is a fragile system
that could dissipate without sufficient support to provide a
bridge to the future health system.
Most of these primary care clinics, now medical homes,
have been sustained on cobbled together funding from a variety
of sources including public funds, such as the Social Services
Block Grant (SSBG) funds. On July 31, 2007, the SSBG funding is
scheduled to end. For a variety of reasons, there were delays
in getting the SSBG funds available to the providers. Fearing
that their expenses wouldn't qualify for reimbursement, many
clinics have avoided using the SSBG funding instead relying on
other resources and on limiting services to their patients. We
are now scrambling to spend the money by the deadline for
spending all the allocated money. If we do not, the funding
will be returned to the Federal Government. Providers in our
community have repeatedly requested an extension of the
deadline so that we can more effectively use the Federal
dollars we've been granted.
An additional option for transitional financial support
would be to allocate the discretionary Deficit Reduction Act
funds could be used for just such a purpose. It could fund a
pilot to assess the impact of a medical home system of care on
improving patient health, care quality and lowering overall
cost. If successful, we could transfer these best practices to
the rest of our State and potentially the nation.
2. Provide financial support for clinicians to help with
retention and recruitment
The need for health care professionals and other staff is
acute. Staff shortages cause many clinics to turn away
patients. Increasingly, recruitment is hampered by care
professionals' rational concerns about the long term financial
viability of the health care system in New Orleans and the lack
of mechanisms to reimburse them for services. To recruit and
retain health care professionals, resources are needed that
will pay qualified providers for services, support educational
loan repayment and defray malpractice costs. HHS and DHH have
been working towards this goal, but the allocated resources are
not likely to be enough. Additionally, application processes
are complex and time consuming. The busy clinicians in this
system need streamlined and accessible mechanisms through which
they can apply for the financial support. Payment for services
rendered could be accomplished through expansion of coverage
and though uncompensated care payments directed at physicians.
3. Assist us as we progress and hold us accountable for our
commitments
The subcommittee would do this effort a great service by
providing assistance and guidance as we move ahead. This
hearing has been quite a catalyst for us locally.-- We have had
been better communication and coordination than in months.--
All of us have been forced to stop and clearly articulate what
would improve access to care immediately.-- Such future
hearings would help hold us accountable for our promises and
allow us to inform the committee members of ongoing success and
continuing needs.
VI. Concluding Remarks
While we work towards agreement on the long term financing
structure of our health care system, we need your help right
now to ensure access to primary care for our citizens. With the
support of the American people and through our public leaders
such as those of you on this Sub-committee, we can restore,
expand and sustain primary care services to our population--
particularly those who are uninsured.
New Orleans survived the hurricanes and the subsequent
flood. But survival, alone, is not the goal of our citizens and
is not a suitable objective for the nation. To thrive, to be
anything close to the city that it was, New Orleans needs a
health care system that all of its citizens can rely upon. The
storm has given us a great opportunity to demonstrate the
health system of the future--one built around the needs of
patients, one readily accessible to all citizens and one that
promotes health rather than simply treating illness.
Thank you.
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[GRAPHIC] [TIFF OMITTED] 36572.007
Testimony of Donald T. Erwin, M.D.
I. Introduction
I would like to thank the chairman and the members of the
committee for their interest in the health of our citizens, and
for holding these hearings. Your commitment to understanding
how we might all work to improve their care is appreciated.
St. Thomas Community Clinic Pre Katrina
The St. Thomas Clinic was established in 1987 by a
partnership between the residents of one of New Orleans's
largest public housing developments (St.Thomas Housing
Development), and concerned leaders in the medical and faith-
based communities. The citizens of this neighborhood wanted
accessible primary and preventive care within a reasonable
distance of their home, with reasonable wait times, and
continuity of their care with the same doctor or group of
providers. The elected leadership of the predominately African
American housing development also insisted that both the clinic
board, and its providers, understand the dynamics of
institutionalized racism and its impact on healthcare for
people of color.
Over the last 20 years this clinic has provided low cost,
efficient care to the uninsured and underinsured through
public/private sources of funding. I was one of the founders of
the St. Thomas Clinic and served as president of the board for
16 years. I was also Chairman of the Department of Medicine at
Ochsner Clinic Foundation much of that time. Ochsner leadership
was very supportive of the relationship with St. Thomas.
Providing appropriate primary, preventive and basic specialty
care to outpatients helped minimize hospitalizations and
emergency room visits. St.Thomas Clinic has been an important
site for the training of Medical Students, Internal Medicine
Residents, Family Practice Residents, Nurse Practitioners, and
Doctor of Pharmacy students from LSU, Ochsner, Xavier and
Tulane. It has been an attractive training site because of its
position in a vibrant community setting and its commitment to
try to reduce health disparities. In addition to Ochsner,
St.Thomas has had innovative partnerships with private
providers such as the EENT Foundation, Touro Infirmary Hospital
and the former Mercy Hospital in New Orleans. These private
providers all recognized the value of the relationship with a
community based clinic trying to address the needs of a large
uninsured population. We all learned that the collaborations of
these public and private entities provided high quality, lower
cost care to the community, while at the same time reducing
emergency room visits and hospitalization rates that burden the
rest of the healthcare delivery system. While receiving grants
from State, city and Federal programs, St.Thomas has remained
independent, not for profit, and is not under the governance of
the State or Federal healthcare clinic systems.
St. Thomas Community Health Center Post Katrina
My physician wife, who had been medical director at
St.Thomas for 12 years and is now on faculty of the LSU School
of Public Health, returned with me to New Orleans in mid-
September after the Hurricane of August 2005. We attended some
of the initial planning meetings for the re-establishment of
health services as the city repopulated. I was soon approached
by faculty and residents from LSU School of Medicine who were
concerned about patients they had treated pre-Katrina at the
Medical Center of Louisiana at New Orleans (MCLNO), and in many
instances they had continued to see while the patients were in
emergency shelters around the State. Many of these patients,
who had evacuated to safer sites, were now returning to New
Orleans and had little access to medical care. Having begun and
operated St.Thomas Clinic before, we were able to relatively
quickly re-open as the St.Thomas Community Health Center and
find supporters who were already familiar with the clinic and
the community. Neighbors immediately appeared with brooms and
mops to help with the clean up. The Baldwin County Baptist
Builders, from Baldwin County, Alabama, were onsite within days
to begin repairing the roof and rebuilding the flooring of the
clinic. Building supplies were extremely scarce, so the
AmeriCares Corporation loaded a tractor trailer with building
supplies in Connecticut and had them at St.Thomas when the
Baptists Builders arrived. For clinical services, it was
necessary to begin anew. Along with clinics such as Covenant
House, we were one of the first primary care clinics to open in
the city. We are, and always have been, open to all patients
regardless of ability to pay.
We have found that the patient population at St.Thomas has
changed since Katrina. The clinic's current patients include
those patients living in a cycle of poverty that St.Thomas has
traditionally cared for, but the clinic now has a large
population of patients who, prior to Katrina, had health
insurance, but lost it when their employer's business failed. A
third population of patients is those now coming to St.Thomas
because they have lost their local physician. At least 50
percent of the physicians practicing in New Orleans pre-Katrina
have not returned. This group of patients who lost their
physicians includes some who have insurance and/or the ability
to pay all, or part of, their bill, calculated on a sliding
scale which is based on Federal poverty guidelines. We now find
that 25 percent of St.Thomas patients can pay for some or all
of their care. Even for those with health insurance in our
community, there are simply not enough physicians to take care
of the patients. While the presence of insured patients helps
St.Thomas be somewhat self sufficient, it also strains our
resources. But the message is clear that the health issues in
New Orleans are not just about the indigent or the uninsured.
Partly because of our history in the community, and partly
because of the dire straits of the city, St.Thomas has received
very generous support from agencies and partners who have
joined with us. Since Katrina, we have received over $1.4
million in grants and contributions, having come from more than
30 separate sources since the storm. Contributions have ranged
from $200 to $500,000. Due to the chaos in our environment, we
do not know precisely how many patients we saw in the first 2-3
months that we were open, but we do know that in the last 15
months we have had approximately 23,000 patient visits. We
average 70-80 patients per day in primary care, with another 30
patients seen who come for breast and pelvic exams including
mammography, and another 20 patients seen for eye exams and
treatment in Optometry. Thus, in the relatively limited space
of 5500 square feet, we are providing care for approximately
120 patients per day.
Any provider working in New Orleans can attest to the fact
that there are few ``brief'' patient visits. The patients have
virtually all sustained losses, in many cases almost
unimaginable, and providing adequate care involves
understanding how the patient can manage their medical
condition within their current life circumstances.
It is impossible not to be impressed with the resiliency of
the people and their determination to put their lives back
together. Most of the patients deal with their stress by
themselves. However, many simply cannot, and we hope to provide
help in other ways, specifically through opening a community
mental health program in space we have just leased.
The list of donors to St.Thomas since Katrina is
impressive. But more important, to us, was the way we were able
to leverage their donations by having donors collaborate with
other donors to help us. We found donors interested in common
issues and were able to combine donations in a complementary
fashion for greater effect. Some of these are described below.
Like other safety net providers left standing after
Katrina, we at St.Thomas realized we were now being called on
to fill huge gaps in the delivery of service. These were
daunting problems, but we often found support from unexpected
sources. The clinic's earliest support came from faith based
institutions, but we also had significant support from public,
private, State and Federal sources that we could not have
anticipated.
While the media frequently reports of what is wrong in New
Orleans, there have been some remarkable collaborations and
partnerships that helped us continue serving our community .
The clinic has been blessed with resources and has tried to be
a good steward of them. Many of our collaborative efforts did
not exist before Katrina. These safety net partnerships and
collaborative efforts provided such positive results, that we
feel they should be maintained the future health care design.
The following are some brief descriptions of a few of the
ways that donations of time and support have been leveraged by
complementary collaborations between St.Thomas and its donor
partners.
(1) Repairing Storm Damage to the Building
Immediately after the storm, neither construction workers
nor building supplies were available locally. We asked friends
from the Baldwin County Alabama Baptist Builders to plan with
the AmeriCares Corporation in Connecticut, and the result was
the timely arrival of both building supplies and construction
crews within days of our asking for their help. They were able
to make the necessary repairs so the clinic could re-open. The
cost for these repairs, if we could have found someone to do
them, would have been in excess of $100,000. It is just one
example of the self-sufficiency that St.Thomas and our sister
clinics showed in getting into service quickly.
(2) Resumption of Clinic Medical Operations
The National Episcopal Church and the Louisiana Diocese of
the Episcopal Church soon after Katrina declared themselves to
be partners with St.Thomas. The church repeatedly worked with
us over the last 18 months to arrange to hire providers and
persuade other donors to partner with us. The church provided
St.Thomas the initial funds to pay LSU School of Medicine for
our initial medical staff and resident trainees. As we set
about to hire permanent staff, the church provided bridge
financing to assure the salaries of 3 full time physicians who
are also jointly on the faculty of LSU Medical School. When
St.Thomas was offered the unique opportunity to provide
cardiology specialty consultations in the clinic, the Diocese
agreed to underwrite the necessary renovations of the space for
cardiology as we sought other grants. Most recently, the clinic
has been able to lease space to begin a community mental health
center. Once again, the Episcopal Diocese of Louisiana
recruited benefactors from out of State to agree to underwrite
the building renovations and hiring of staff.
In great part due to the promise of secure funding by the
church, St.Thomas now has three full time adult primary care
providers, all of whom are jointly on the faculty of the LSU
School of Medicine and /or the LSU School of Public Health. We
have a full time pediatrician who joined us from the community.
We have 5 part time specialty care providers. Specialty
services St.Thomas offers now include cardiology (see below),
gynecology (by a community gynecologist), pulmonology and
rheumatology (from their respective departments at LSU School
of Medicine), optometry, (funded by the EENT foundation), and
nephrology (from a volunteer working at another State medical
facility). Each of the rheumatology, pulmonology and nephrology
specialty providers, while very beneficial in reducing
emergency room visits and avoiding hospitalization of our
patients, costs St.Thomas approximately $25,000 annually and
visit the clinic one half day per week.
3) Breast and Cervical Disease Prevention and Management:
The LSU School of Public Health recognized that St.Thomas
could provide the site for them to maintain operations of their
Louisiana Breast and Cervical Health program, which is
sponsored by the Centers for Disease Control and Prevention.
Recognizing this possibility, the School of Public Health
helped St.Thomas develop a consortium of funders that includes
the Avon Corporation, Komen Foundation, and the United Way.
This collaboration provided over $530,000 to St.Thomas. The
medical outcome of this collaboration is that St.Thomas
Community Health Center is the only site in the city where
uninsured women can receive breast cancer screening complete
with both screening and diagnostic mammography, breast
biopsies, and follow up care arranged with providers who will
care for our breast cancer patients for the Medicaid rate we
can provide.
(4) Specialized Cardiology Consultations and Care
One of the most remarkable and unexpected collaborations
has resulted in St.Thomas being able to offer cardiac
consultative tests and specialized patient management. At the
suggestion of Dr Keith C Ferdinand, a nationally recognized New
Orleans cardiologist, The Association of Black Cardiologists
(ABC) approached the Morehouse School of Medicine on behalf of
St.Thomas to provide cardiac care to the community. The ABC
knew of St.Thomas from the clinic's previous work dealing with
health care disparities. Cardiac care was an urgent issue for
our uninsured community, as patients requiring elective cardiac
evaluations and diagnostic testing had to travel either 60 or
80 miles away to one of the open Charity Hospitals.
Spearheading the effort, the ABC and the Morehouse School of
Medicine helped develop a group of providers, manufacturers and
professional organizations who all agreed to help St.Thomas
meet the need for cardiac care in the uninsured community. This
collaboration now includes not only ABC and Morehouse, but also
professional groups including the National Board of the
American College of Cardiology, the Louisiana Chapter of the
American College of Cardiology, the Ochsner Clinic Foundation
Department of Cardiology, the New Orleans Medical Foundation,
and corporations such as Astra Zeneca, Cardiac Science, and the
Toshiba Corporation. Providing direct care to St.Thomas, a
community cardiologist (Dr Gary Sander), and Ochsner Clinic
Foundation Cardiologists come to St.Thomas 2 half-days a week
to see our patients and supervise testing. This diagnostic
testing now includes standard EKGs, echocardiograms, 24 hour
Holter monitoring and interpretation, and most recently, stress
echocardiography. We are currently negotiating for hospital
support when Invasive catheterization and surgery is necessary.
Our physicians are certain that having these diagnostic and
management services available in the clinic, especially having
cardiologists help with the management of complex patients, has
resulted in a reduction of both hospitalizations, and visits to
the emergency room for our patients with heart disease.
The volume of patients who are seen in cardiology or any
of the other specialty areas at St.Thomas, are not just from St
Thomas Clinic alone. We have invited all of our sister clinics,
i.e. Daughters of Charity, Common Ground, St Charles CHC, and
Covenant House, to use these any of these specialty
consultations.
We are very pleased that the Medical Center of Louisiana
at University Hospital is now open and also providing cardiac
specialty care. This is a great step forward for our community.
We hope to continue to partner with, and augment State and
local efforts, and the community is hopeful additional beds
will soon open for interventional cardiac care for the
uninsured.
(5) Enhanced Systems Development
The Partners for Access to Health Care, (PATH) a
subsidiary of the Louisiana Public Health Institute has
provided hardware, software and licensing support for an
Electronic Medical Record for the St.Thomas clinic. Once this
became available, both public and a private support came to
St.Thomas to maximize our systems of registration, billing,
coding and collection. Blue Cross Blue Shield Foundation of
Louisiana is able to provide sophisticated business support and
personnel, and they are joining with one of our sister clinics,
the Saint Charles Community Health Center to assist in applying
this expertise to the every day operations at St.Thomas. As we
become more efficient with our different systems, we feel we
can increase the number of patients seen significantly, thus
not only increasing the number of patients seen, but also
reducing the cost of care per patient borne by St. Thomas .
(6) Another partnership that has been made available to us
is an alliance with the Eye Ear Nose and Throat Foundation.
This foundation provides support for St.Thomas patients with
Eye or Ear Nose and Throat disease. These patients can be seen
in the private sector once they have been screened by
St.Thomas. This has been crucial to protect the vision of our
diabetic patients at risk for serious diabetic eye diseases.
Several local hospitals, and private Eye, Ear, Nose and Throat
physicians, have agreed to see our patients for the Medicare
rate fees the EENT Foundation provides. This has been
especially important since the public hospital ENT programs are
still located in Baton Rouge and will be for the foreseeable
future.
(7) Another very important ally has been the Bush Clinton
Katrina Fund, which gave us our largest donation to date,
$500,000. While critically important, like so many of our
grants, this is a one time only grant, and must be spent within
one year of receipt.
(8) The last source of support to highlight is the Social
Service Block Grant, which was made available by the Federal
Government to safety net clinics. As these funds were being
negotiated and the grant programs developed, the Louisiana
State Department of Health and Hospitals, led by Dr Fred Cerise
and Ms Kristi Nichols, aggressively fought for funds for safety
net providers like St.Thomas and sped up the negotiations
necessary to get the funds to these providers. St.Thomas
received an SSBG grant of $755,000 in the second year of our
post Katrina operations. The estimated operating deficit of the
clinic for that year was $800,000, demonstrating how critical
the timely distribution of those funds was for St.Thomas. Like
the Bush Clinton Katrina Relief Fund, our gratitude for this
funding is great. Nonetheless, one time grants highlight our
need to identify and secure stable funding to sustain
operations.
In addition to the above contributions, we have received
generous support from other charitable and relief
organizations, including the National Association of Free
Clinics, Robert Wood Johnson Foundation, Operation USA, Direct
Relief International, individual Presbyterian churches and
Episcopal parishes, the Acadiana Foundation, the Area Health
Education Foundation, and individual, sometimes anonymous,
donors.
One of the important reasons for the collaborations among
these clinics is that enhanced primary care is clearly the best
way to provide convenient, high quality care with provider
continuity. This is important to patients, but it is also the
most effective way to reduce emergency room visits and
hospitalizations. The community clinics that make up the PATH
organization all want to continue to have linkage to the
academic specialty services at Medical Center of New Orleans,
and we are pleased to see how effectively Dr. Dwayne Thomas,
Dr. Cathi Fontenot and other members of the management of
University Hospital at the Medical Center of Louisiana have
been at getting the hospital open and specialty services
brought back. But in spite of their effectiveness, there are
still limited beds in the University Hospital that are just not
yet resolved.
There exists within the PATH organization a sub group of 5
clinics that are similar in that they are all independent, not-
for-profit, clinics. None are part of the City of New Orleans
Clinics, or the Medical Center of Louisiana at New Orleans. The
critical services provided by these clinics have become more
important since Katrina, but they have no guaranteed recurrent
funding. They include St.Thomas Community Health Center, St.
Charles Community Health Center, Common Ground Clinic, Covenant
House Clinic, and Daughters of Charity Health Center. We share
common goals, and try to support each other, and have learned
the value of sharing resources, even if limited. Thus,
St.Thomas Clinic shares all the specialty services we have
listed above with each of these five clinics, and each of them,
in turn, has provided varied useful resources to St.Thomas. We
are currently seeking shared support based on the premise that
funders might well be more receptive to helping us in order to
support the development of a network to improve our efficiency
and effectiveness as we maximize our community support
services.
Conclusion
The funding for St. Thomas Community Health Center has been
substantial but it is a patchwork of organizations that have
been generous to us. It has taken resourcefulness, prayer, and
extensive community relationships to develop support from more
than 30 partners who help St. Thomas provide the level of
service it provides. Many of the grants to the clinic have been
related to Katrina, and are one time only events. While
appreciative of the generosity of our partners, the quest for
ongoing funding is constant.
As we consider funding the future of St. Thomas, a major
issue is timing. Most experts agree that even if, as we hope,
the Medical Center of Louisiana at New Orleans can be rebuilt
in a way that adequately addresses the need for primary care,
prevention, specialty care and hospitalization for the
uninsured, at the earliest, the process will take years. The
St. Thomas Clinic was begun by citizens asking for community
based, accessible and patient centered care. The clinic
provided that over the years and now, thanks to generous
funding, is doing it on a larger scale and is also meeting some
of the specialty care needs that is currently limited or non
existent at the State hospital. It is likely that the services
we provide will be needed for the foreseeable future as the
health care system is being rebuilt. The St. Thomas Community
Health Center, and others like it, arose from a need before and
after Katrina to address issues of healthcare for the uninsured
in New Orleans. We would ask that Congress consider assisting
these clinics to continue to provide these services with gap
funding, and to provide consultative support to help us
structure a sustainable clinic network.
Whether they be called medical homes or community based
clinics, we feel that clinics like St. Thomas and our sister
clinics in PATH organization provide important resources for
health care in the future. We provide not only compassionate,
skilled, and readily available care, but we have also learned
how to develop our collaborative efforts to leverage the care
that any and all of us are able to provide independently. What
we need is on site assistance in formal network development,
and strategic suggestions on building sustainable funding.
There is considerable debate at present about the specific
health care program that should be developed for the future of
the State of Louisiana. I would not want anyone to construe my
testimony before you, to be an endorsement of one group over
the other, private versus public. I can honestly say that after
30 years in on part or another of the health system in New
Orleans, I have been very heartened at the energy and
determination of my colleagues at Charity Hospital (MCLNO), the
commitment and sincerity of the leaders of the State Department
of Health and Hospitals, and also physicians in the private
sector, all of whom are trying to address this overwhelming
challenge of providing basic healthcare to the uninsured and
underinsured members of our community. We appreciate the
importance of the patient having choice in any health care
system. We also appreciate the quality and care benefits that
come from a medical home in which one can find both primary
care and access to specialty services and hospitalization when
necessary. We want to continue to develop efficiencies and the
other components of a true medical home. We feel this is the
best way to provide comprehensive primary care to the
community.
Our experience at St. Thomas is that this community
desires respectful and readily accessible access to care. They
want, and deserve, timely evaluation and treatment for diseases
found in the primary care setting. All our citizens deserve to
have the opportunity to prevent chronic diseases and to detect
problems such as coronary heart disease and cancer before they
cause lifelong disability or death. We know that timely,
appropriate specialty care in the outpatient setting is an
integral part of comprehensive care. Management of patients by
the collaboration of primary care providers, and specialists
when appropriate, provides the most cost effective, highest
quality care while it simultaneously lowers emergency room
visits and hospitalizations.
What we have done over the years at St. Thomas, and
particularly since Hurricane Katrina, has been to try, on a
small scale, to provide both primary and preventive care, with
specialty consultations as possible. The opportunities,
collaboration, and generosity of the American people following
Katrina has allowed St. Thomas to do more than ever before.
The St. Thomas Community Health Center, and our group of
health clinics that have shouldered the majority of care for
the last 18 months, now seek the help of this committee to be
able to continue these services while fully supporting the
restoration of services at MCLNO. We also urge that clinics
with proven track records in the community such as ours be
considered to be integral parts of whatever plans are
ultimately developed for the long term.
Our current mission:
(1) To continue to provide primary care to all patients,
regardless of their ability to pay.
(2) To provide services to those who, in spite of their
ability to pay, cannot find a physician.
(3) To continue to develop outpatient specialty
consultative services and to make them available to other
primary care providers, to improve outcomes and reduce reliance
on the emergency rooms and hospitals.
(4) To develop and provide a community based mental health
center, focusing on youth, and families, who are dealing with
the continuing stress related to the loss of their community
caused by Katrina.
(5) And most important, to develop the appropriate
networking infrastructure and efficiencies to enhance and
sustain the services we deliver.
Our most pressing needs for the immediate future include:
(1) Stable, dependable, gap funding until the new self-
sustaining health care model is in place.
(2) Available specialty consultations for complicated
patients, (for the management of cancer, gastro-intestinal
diseases and other complex conditions, and surgical specialty
care such as urology, and orthopedics).
(3) Mental health providers, including inpatient mental
health beds and ongoing outpatient mental health services.
(4) Improving our systems support to maximize the numbers
of patients we can effectively and appropriately see.
I would once again thank the chairman and the members of
the committee for the opportunity to participate in this
hearing.
[Dr. Erwin's answers to submitted questions from Mr.
Whitfield follow:]
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Testimony of Frederick P. Cerise, M.D., M.P.H.
Mr. Chairman and members of the committee thank you for
the opportunity to testify today on the continuing concerns and
immediate health care needs in the New Orleans region. I am Dr.
Fred Cerise, Secretary of the Louisiana Department of Health
and Hospitals, the leading State agency for health care in
Louisiana.
Background: Louisiana struggles with the same health care
delivery system issues affecting the rest of the country. Our
fragmented system that operates largely in a fee for service
environment results in a health care system characterized by
uneven quality of care, rising costs and inequitable access to
care. In 2004, Louisiana spent $19.4 billion on health care
services in Louisiana\1\ and from 2000-06 health care premiums
for Louisiana families grew nearly 5 times faster than
earnings.\2\
In many areas, capacity and utilization in Louisiana are
well above the national average. A snapshot of the status in
Louisiana prior to Hurricanes Katrina and Rita shows the
following:
Overall Medicare spending per capita\3\ K--1st
Hospital beds per capita--9th
Medicare hospital days--2d
Overall hospital admissions--4th
Overall emergency department visits--4th
Medicare home health, number served per capita--
1st
Medicare home health, number of visits per person
served\4\
Overall prescriptions filled for children and
elderly--3d
Overall Medicare quality ranking\5\--50th
Louisiana is further characterized by a high uninsured
rate, a high level of poverty, and poor health status. The
uninsured consume far less care than those with insurance,\6\
they are not the driving force behind the above statistics.
The largest provider of care for the uninsured is
Louisiana's State operated system run by the Louisiana State
University (LSU) Health Care Services Division (HCSD) and
Health Sciences Center (HSC). This system is comprised of 10
hospitals and over 250 outpatient clinics statewide. LSU-HCSD,
which includes New Orleans, had nearly 900,000 outpatient
visits, including 626,000 clinic visits during the 2005-06
fiscal year.\7\
Reimbursement for these services is primarily funded by
utilizing disproportionate share hospital (DSH) funds. The DSH
program was created to provide funding to hospitals that served
a ``disproportionate share'' of Medicaid and uninsured patients
and is a component of the Medicaid program. Subsequently, it is
jointly funded by the State and Federal Governments.
Louisiana's ``State match rate'' is approximately 30 percent--
so for every 30 cents the State puts forward, the Federal
Government matches it with 70 cents. Additionally, each State
has a DSH cap. The total DSH available for Louisiana in fiscal
year 2007 is $1.05 billion.
DSH funds in Louisiana are primarily allocated to the LSU
system and community hospitals. Although DSH funds are a key
source of funding for the uninsured in Louisiana, there are
some limitations to the program. For example, only hospitals
can be reimbursed with DSH funds. This means that only
hospital-based clinics can receive reimbursement through the
DSH program. This is less of an issue for the LSU system, since
it is an integrated system with both hospitals and clinics.
However, the DSH program inadvertently supports high-cost
emergency department care when primary care through a clinic
might be more appropriate. Furthermore, DSH funds are used for
reimbursing health care services--but cannot be used to
reimburse a physician or other health care professionals that
provide care to the uninsured.
Louisiana is not unique in the existence of this type of
safety net; we are unique in that it is organized as a
statewide system. Through this system, people who are unable to
afford health care can access services, including primary,
preventive and specialty care as well as hospital services.
While variable across the State, access to many services is
constrained by available funding.
Considering the high utilization, rising costs, uneven
quality, and lack of equitable access to health care in
Louisiana, the State's approach to health care reform, both
pre- and post-Katrina has been aimed at making systemic
changes.
Louisiana Health Care Redesign Collaborative: After
Hurricane Katrina, the Louisiana Health Care Redesign
Collaborative was created through a legislative resolution to
respond to the health care issues in the New Orleans region
(Jefferson, Orleans, Plaquemines, and St. Bernard parishes).
The Collaborative was a forty member group charged with
creating recommendations for a health care system for New
Orleans driven by quality and incorporating evidence-based
practices and accepted standards of care. The Collaborative
adopted the following vision: Health care in Louisiana will be
patient-centered, quality-driven, sustainable and accessible to
all citizens. The backbone of a redesigned system of care put
forward by the Collaborative is the ``medical home.''
The proposed medical home system is consistent with
recommendations made by a number of professional societies such
as the American Academy of Pediatrics, the American Academy of
Family Physicians, and the American College of Physicians. It
also has qualities and expectations consistent with those of a
high performing health system as described by the Commonwealth
Fund and of a redesigned system as characterized by the
Institute of Medicine.
This new system will provide health promotion, disease
prevention, health maintenance, behavioral health services,
patient education, and diagnosis and treatment of acute and
chronic illnesses. The medical home is the base from which
other needed services are managed and coordinated in order to
provide the most effective and efficient care. This includes
specialty care, inpatient care, community preventive services
and medical home extension services for complex care needs. The
center of the medical home is a primary care provider who
partners with the patient to coordinate and facilitate care.
The medical home does not restrict patient access to services--
rather it helps ensure that the patient receives the right
services.
Ensuring the coordination and comprehensive approach of the
medical home model over time will improve the efficiency and
effectiveness of the health care system and ultimately improve
health outcomes.
The other three main components of the redesign concept
are:
Health Information Technology (HIT)--HIT is the
key to creating ``system-ness'' and can allow the seamless
sharing of electronic information to improve efficiency and
patient safety. Additionally, HIT can be used to inform
clinical practices and facilitate data reporting which are key
components of a quality agenda.
Louisiana Health Care Quality Forum (LHCQF) ``The
LHCQF will function as a ``learning system'' that will monitor
population health measures across providers and payer systems
and actively engage with health care organizations to implement
quality improvements, increase cost-effectiveness, and achieve
better outcomes statewide. It will improve the quality of
health and health care throughout Louisiana in a cost effective
and transparent manner in a safe, peer protected environment.
Coverage for Services - Another major concept is
the creation of a mechanism (the Connector) which would match
individuals needing health insurance to affordable insurance
options, thus offering affordable health insurance coverage to
an expanded number of uninsured individuals in the State.
In response to the Collaborative's concept, the Federal
Department of Health and Human Services put forward a proposal
that is consistent with the President's Affordable Choices
Grants proposal that was announced in the 2007 State of the
Union address. HHS proposed a statewide coverage expansion that
would insure 319,000 uninsured through private insurance. This
proposal would be financed by savings from better managing
Louisiana's Medicaid program and by redirecting $770 million in
disproportionate share hospital (DSH) funds currently spent in
the safety net system.
While appreciative of the effort to insure more
individuals, the State recognizes serious gaps in the proposal.
Through our analysis, the HHS proposal would leave 300,000 to
400,000 citizens without insurance coverage. Additionally,
current funding ($770 million) for the safety net would be
eliminated if the State were to implement the CMS proposal. The
use of incorrect cost projections, the omission of high-cost
populations, and the use of unrealistic managed care discounts
in the HHS proposal suggests that coverage would be expanded to
fewer than the projected 319,000.
Louisiana has learned from those that have traveled this
road before. Massachusetts, which is breaking ground with its
mandate for health insurance coverage, spent many years working
towards this goal. If Louisiana were to cover half of its
uninsured as optimistically described above, we would end where
Massachusetts began just prior to its 2006 reform legislation--
about 10 percent uninsured but without a safety net system of
care. As a State with nearly 18 percent uninsured and 45
percent of its population at 200 percent of the Federal Poverty
Level or below,\8\ we understand that we must lay the
groundwork before we can make such great leaps. The groundwork
includes efforts aimed at both insuring more people, and also,
very importantly, improving our safety net and the delivery
system in general.
John Wennberg, Director of the Center for the Evaluative
Clinical Services at Dartmouth Medical School, and others have
demonstrated that in healthcare, capacity is a strong driver
for demand. As a result of Katrina, the New Orleans region lost
a large amount of capacity. However, capacity is tied to other
important pieces of the utilization equation, such as how care
delivery is coordinated and how it is reimbursed.
Those system design changes have not occurred; therefore we
should not expect a smooth transition to a lower capacity
system. Further, in most areas, capacity is now well below
national norms. The lower capacity and specifically, the lack
of ready access to coordinated primary care or post-acute care,
has resulted in the stressed medical environment we are
experiencing today in New Orleans.
So our challenge is twofold. We must first meet immediate
needs while ensuring that, in the process, we support the
rebirth of a better overall system of care. The vision for a
system to replace the lost capacity is one that adheres to the
aims set forth by the Institute of Medicine: safe, effective,
patient-centered, timely, efficient, and equitable. It is a
patient-centered system predicated on access to primary care
that provides evidence-based preventive services and tracks
those with chronic disease to ensure appropriate management. It
provides ready access to appropriate services and information
when necessary and is convenient for patients, coordinated
among providers along the continuum of care, and supported by a
system of electronic medical records to improve safety, quality
and efficiency.
The current gaps in the delivery system have provided the
opportunity for systems change. We will continue to move
forward with health care reform for Louisiana--but we must also
ensure the New Orleans region can recover to meet our citizen's
health care needs today. My testimony today will focus on the
immediate and short-term health care needs for the New Orleans
region of Louisiana.
Post-Katrina Health Care in the New Orleans Region:
Hurricane Katrina caused a significant disruption in the health
care delivery system in New Orleans. Prior to Katrina, care for
the uninsured in the New Orleans region was delivered primarily
in the public hospital system and clinics and to a lesser
extent, federally qualified health centers (FQHCs).
Uncompensated care for the community hospitals in the region
was less than 4 percent. According to the
PricewaterhouseCoopers Report on Louisiana HealthCare Delivery
and Financing System, the region had an oversupply of short-
term acute care hospital beds and an undersupply of long-term
care beds.
Immediately after the storm, only 7 of 21 acute care
hospitals were open with staffed beds at less than half of the
pre-Katrina total. The nursing home capacity was reduced from
4,954 to 2,735 beds. The largest health care system for the
uninsured, the LSU-HCSD system, was not operational.\9\ The
closure of the LSU-HCSD hospital in New Orleans also eliminated
their Level I trauma center, which was one of only two in the
State. In addition to the impact on the infrastructure, the
evacuation of people from the area led to the largest efflux of
health care providers in U.S. history.
The University of North Carolina at Chapel Hill estimated
that almost 6,000 active, patient-care physicians along the
Gulf Coast were dislocated by the storm. Over two-thirds--
4,486--of those were in the three central New Orleans area
parishes that were evacuated. The study also estimates that
over 35 percent of these dislocated physicians were primary
care physicians. The loss of medical manpower in hurricane-
affected areas created a critical shortage of physicians all
across south Louisiana. Similar shortages have occurred with
nurses and other licensed and trained health care providers.
There have been a number of efforts over the past year and
a half to ameliorate the situation in the New Orleans region.
The Federal Deficit Reduction Act appropriated $2 billion to
States affected by Hurricane Katrina. As a result, the State
implemented a Katrina 1115 waiver to provide coverage to our
citizens that evacuated to other States and to provide payment
to providers within the State for uncompensated care (UCC).
This provided $132,091,048 in much needed relief to providers
for uncompensated care between August 2005 and January 2006.
Additionally, the State was able to use approximately
$680,569,383 to supplement State funding for its Medicaid
program. The Medicaid funding relief came at a critical
juncture in early 2006 as State revenues had sharply declined,
all State agencies were implementing budget reductions, and the
State had issued an emergency rule reducing Medicaid
reimbursement rates to providers by roughly 10 percent.
Hospitals: Recognizing that the usual source of inpatient
care for the uninsured in the Orleans region was not
operational and that the Katrina UCC pool was time limited, the
State created a mechanism to pay community hospitals for UCC
rendered for the remainder of the State fiscal year, between
February and June 2006. A total of $52,494,904 was reimbursed
to community hospitals. Currently, physician costs are not
considered an allowable cost and cannot receive reimbursement
through the DSH program. A request to receive Federal match to
pay physician UCC during this period was requested but not
approved.
Two payment increases were subsequently approved by the
2006 Louisiana Legislature. First, Medicaid payments for
hospitals were increased by $38 million. Second, a Community
Hospital DSH Pool was established, allocating $120 million for
UCC for community hospitals from July 2006 through June 2007.
Although a proposal was put forward by the State to reimburse
hospitals in the Katrina and Rita affected parishes at 90
percent of uncompensated care costs, the hospital association
preferred an approach that provided less funding to the Katrina
and Rita affected regions and spread the UCC funds more thinly
across the State to potentially include all hospitals in the
State, including those not in the affected regions and not
significantly impacted by evacuees.
To date, $37,995,972 has been paid to the community
hospitals; it is likely that the full $120 million will not be
expended according to the formula adopted in the State
appropriations bill.
Primary Care and Behavioral Health: Access to primary care
and behavioral health has been limited post-Katrina. This is
particularly true for those without insurance. Approximately
$16.5 million of the Social Services Block Grant (SSBG) funding
was dedicated to restoring primary care in the New Orleans
region after Hurricane Katrina to restoring critical primary
and preventive health care services. This funding expires
August 2007. In addition to utilizing this funding for direct
service delivery, SSBG funding also has been used to enable
these clinics to prepare to become future medical homes
delivery sites. The State targeted a portion of SSBG funding to
the implementation of electronic medical records, quality
improvement initiatives and the development of networking
capabilities across clinic sites to achieve interoperability
and system-wide patient education and outreach.
SSBG funds are also being used to restore and expand mental
health services, substance abuse treatment and prevention, and
developmental disability services for children, adolescents and
adults in need of care in these areas. Through this funding,
efforts are also being targeted at the creation of more
appropriate community based treatment options to prevent
unnecessary or inappropriate institutional care.
Federal Emergency Management Agency (FEMA) and Substance
Abuse and Mental Health Services Administration (SAMHSA) funds
have been used to:
provide psychological debriefing and stress
management interventions to the public sector workforce;
expand the number of addiction counselors in the
State; and
develop and implement the ``Louisiana Spirit--
Immediate Crisis Services Program, which is designed to deliver
crisis and mobile counseling to persons impacted by the
hurricanes.
The State has also provided funding to open 45 beds for
behavioral health for adults and children.
Health Care Workforce: The Redesign Collaborative
identified a number of short-term issues and made requests to
HHS for assistance, including one to establish the Greater New
Orleans Health Services Corps (GNOHSC). A major challenge
remains the inability to retain a medical workforce. HHS
awarded Louisiana with a workforce grant of $15 million in
February 2007.
The grant, through the GHNOHS, will provide salary,
relocation costs, bonuses, and premium payments for medical
malpractice for providers that commit to practice in the region
for the next three years. Eligible providers include
physicians, dentists, physician assistants, nurse
practitioners, nurse midwives, dental hygienists,
psychologists, counselors, social workers and pharmacists.
New workforce competition, as a result of Katrina, has
highlighted traditionally low salaries of direct care
professionals for the elderly and people with disabilities. The
average salary for direct support professionals in Louisiana is
$6.68, which is below the national average. The State is
increasing the wages for these workers by $2/hours to help
retain these critically needed workers. The annual cost to
Medicaid will be $110 million.
Another short-term request from the Collaborative to HHS
was for an adjustment to the Medicare wage index to reflect
current costs. The wage index typically lags three years.
Hospitals estimated the cost to be $67.7 million a year for
three years. A $71 million grant to hospitals and skilled
nursing facilities was received from HHS.
Health Information Technology: Louisiana received a $3.7
million contract from the Office of the National Coordinator
for Health Information Technology (ONCHIT) to develop a
prototype for health information exchange, which has since been
successfully demonstrated. This contract is part of the Gulf
Coast Digital Recovery Effort. The State assisted in the
establishment of the Gulf Coast Health Information Technology
Task Force that the Southern Governor's Association convened.
Other HIT efforts include the launch of KatrinaHealth.org which
allowed providers to access prescription drug information for
evacuees.
Current Status of the System: Combined, these efforts have
significantly improved health care in the New Orleans region.
However, issues remain. Over time, the impacted area has seen
slight increases in bed capacity, but there remains a shortage
of acute care beds compared to national standards. The current
plan in the LSU-HCSD hospitals is to phase-in an additional 75
beds by July 2007. The staffing and reimbursement for hospitals
continue to pose problems.
Today, there are 26 safety net primary health care sites
that are providing services in the New Orleans region. These
sites include federally qualified health centers, Tulane
outpatient clinics, LSU-HCSD outpatient clinics, mobile
clinics, city and parish health service sites, hospital
outpatient clinics, rural health clinics and non-profit
community-based practices. However, based on the current
population, there remains a shortage of primary care providers.
Increased demand for primary care providers will likely occur
as the region continues to repopulate.
The region also suffers from a significant shortage of
specialists. While LSU-HCSD has been able to resume a number of
specialty services as space and staff have become available,
there remains the lack of some essential specialty services to
support the primary care sites serving Medicaid and the
uninsured. The area is still below national norms for nursing
facility beds.
Immediate Health Care Needs for the New Orleans Region: The
health care system is still challenged today. The actions taken
over the past year and a half have helped to improve access to
care, workforce issues and infrastructure--but problems remain.
Access to care, particularly for the uninsured, is difficult.
Rising costs, due to contract labor and higher property and
casualty insurance costs are impacting providers. The average
length of stay in hospitals is above pre-Katrina averages.
These are among the immediate needs to be addressed in the New
Orleans region.
Broadly, the immediate continuing needs fall into one of
three categories: access to care, workforce recruitment and
retention, and infrastructure requirements. The specific needs
are outlined below:
Primary Care Capacity: Currently, there is a shortage of
primary care providers in the New Orleans region that is
affecting all other components of the system. Based on HRSA
standards, we have a shortage of 49 primary care providers who
are available and willing to serve the Medicaid and uninsured
populations. Hospitals across the region report seeing a
population with more advanced disease than pre- Katrina, more
patients without a regular source of care, and even more
limited options for discharge and follow-up care in the
communities.
Solution: Establish sufficient primary care capacity in a
manner consistent with the redesigned system of care envisioned
by the Collaborative by sustaining operational support provided
by SSBG funds to safety net clinics and by funding ten new
medical homes. Medical Homes of sufficient size and scope to
meet the needs of the uninsured population will be established
in a fashion consistent with the principles outlined by the
Collaborative. The medical home criteria would include not only
quality expectations but also care coordination and access
expectations to ensure timely care is available outside of
emergency departments through after hours clinics.
The above approach will have the effect of providing
assurances of income necessary to attract and retain providers,
while relieving the burdens of fixed costs. This will foster
the growth of what is designed to be a high performance
delivery system.
Workforce Recruitment and Retention: Louisiana facilities
now have to employ increasing amounts of contract labor to
sustain staffing needs. The added complexity of inadequate and
short supply of desirable housing for health care professionals
continues to result in a lack of physician staff, mental health
professionals, dentists, nurses, and others willing to remain
in or locate in the greater New Orleans area. The ability to
expand capacity to meet the health care needs in the region is
hindered by the lack of available workforce.
Solution: Fully implement the Greater New Orleans Health
Services Corps Program. Initially, Louisiana requested $120
million to support health care workforce recruitment and
retention. Fifteen million dollars have been granted to the
State--which will allow the State to institute the program.
However, we continue to estimate that it will cost $120 million
to fully implement the program. This will provide for
incentives for physicians, dentists, nurses, and other
professional staff. In exchange for the financial support,
providers must commit to serve in the region for three years.
Behavioral Health: Lack of access to necessary community
based services and housing supports for individuals with mental
illness and other behavioral health needs shifts care to more
acute services. The shortage of community services for this
population, a situation only exacerbated after Hurricane
Katrina, results in the reliance for services on the hospital
emergency departments, an area already strained due to the lack
of adequate primary care in the area. In addition, the loss of
psychiatric care beds in the area from 274 to 180 post-Katrina
and the slow return of the community based mental health
services only furthers the lack of access to care.
Solution: Develop, implement, and fund a five year
redevelopment and mitigation/prevention plan for behavioral
health services; and expand Medicaid coverage to people with
severe mental illness. The State requests a partnership with
FEMA and other governmental entities in the development and
implementation of a point by point plan along with secure
funding for a five years. This plan allows for the
reestablishment of a competent mental health system in the
greater New Orleans region and other contiguous parishes.
This five year plan, estimated at $170,000,000 would
include crisis counseling under the existing FEMA Disaster
Relief, as well as direct treatment dollars for services
including psychiatric hospitalization, crisis intervention,
suicide prevention, substance abuse treatment and long-term
ambulatory treatment of psychiatric conditions. This funding
and support from FEMA will stabilize the behavioral health
system for the Orleans region.
Further, the concept paper the State put forward to HHS
included a request to include individuals with serious mental
illness as a Medicaid eligible population. This would allow the
State to provide broader access to services for these
individuals.
Medicare Wage Index: The short supply of health care
providers is resulting in increased competition among providers
for professional and non-professional staff. The effect is a
significant rise in labor costs. Compounding the problem is the
increase in the length of stay that hospitals are reporting.
This rise in costs is not reflected in the prices established
by the Medicare fixed payment system.
Solution: Provide funding for costs related to the Medicare
wage index. HHS awarded Louisiana a $71 million grant for
hospitals and skilled nursing facilities to address the
increased costs providers are experiencing as a result of the
rising labor costs. While very helpful, this one time grant
does not address the entire three year lag in the Medicare wage
index calculation. The fiscal estimate for 2 years is $67
million/year for hospitals and $6.9 million/year for skilled
nursing facilities.
DSH Flexibility: Two significant roadblocks to increasing
health care capacity and access to health services in the New
Orleans region are (1) the inability to use DSH funding for
non-institutional care and (2) the inability to use DSH to
reimburse for physician services. In order to receive DSH funds
today, health care services must be funded by a hospital. While
the State has created great capacity in a clinic system
associated with public hospitals, this limits flexibility in
development of outpatient capacity. Further, while physician
costs are an essential component of delivering health care,
they are not reimbursable through DSH.
Solution: Allow the redirection of DSH funds to support
non-institutional care; and allow DSH funds for physician
services. The DSH redirection will provide great relief by
creating a funding mechanism to reimburse physicians for
treating the uninsured and by supporting clinics that provide
primary and preventive care. The State also proposes to
redirect DSH funds in the New Orleans region for a pilot to
reduce the cost of private insurance for small employers and
their low-income employees. Ultimately, redirecting the DSH
funds will allow the groundwork for creating an integrated
system of care for the New Orleans region. This solution does
not require additional funding.
Health Information Technology (HIT): Hurricane Katrina
highlighted the importance of interoperable HIT. After the
storm, providers had difficulty communicating with each other
across the State and the vast majority patients who were
displaced as well as the providers caring for them did not have
access to patient records. While HIT is an important component
of hurricane preparedness, it creates value everyday by
improving patient safety and health system efficiency. As
physician practices recover, and as we support providers in
settings to care for the uninsured, it makes sense to implement
a modern system of health information exchange into the
process. The devastation in the New Orleans region provides an
unprecedented opportunity to make a significant imprint of HIT
in a large metropolitan area.
Solution: Support electronic medical record (EMR) adoption
and continue to support the Louisiana Health Information
Exchange (LaHIE) project. The Office of the National
Coordinator for Health Information Technology contracted with
Louisiana immediately after Hurricane Katrina to develop a
health information exchange, as part of the Gulf Coast Digital
Recovery effort. This $3.7 contract will expire at the end of
this month. Continued support of LaHIE will cost approximately
$1 million per year. The other essential component is the
adoption of EMRs by providers. The State estimates that it will
cost $17.7 million over a five year period for the New Orleans
region primary care providers to fully adopt EMRs. The State is
would like to continue and expand this successful partnership
with the Federal Government.
Developmental Disabilities: The ongoing need for community-
integrated housing that can support those with significant
disabilities is critical for the recovery and for the
healthcare delivery system in south Louisiana. Prior to
Hurricanes Katrina and Rita, people with disabilities were
disproportionately represented among the homeless and faced
extraordinary barriers in accessing and maintaining access to
affordable housing. As a result of the disaster, many more have
been rendered homeless or have been unable to move from what
should have been temporary shelter in institutions and other
restrictive settings because of a lack of affordable housing
coordinated with supportive services. This also affects the
ability of healthcare providers to discharge individuals from
acute care settings, and housing instability often leads to a
revolving door of reentry into emergency and acute care
services.
Solution: Provide, through the U.S. Department of Housing
and Urban Development, an equal number of Section 8 project-
based Housing Choice Vouchers to be used in conjunction with
the 3,000 units of Permanent Supportive Housing (PSH).
Louisiana has made a commitment to develop 3,000 units of
Permanent Supportive Housing as part of the recovery effort.
The State has worked closely with local and national advocates
who are strongly in favor of this commitment to PSH. These
vouchers will ensure that the housing designated for PHS will,
in fact, be affordable to individuals with disabilities, many
of whom live on SSI and have incomes at and below 20 percent of
Area Median Income. In order for this recovery to be accessible
to all Louisianans, the Federal Government's provision of 3,000
section 8 project-based Housing Choice Vouchers specifically
for use in providing PHS as defined in the Louisiana Road Home
Plan is essential.
PSH integrates affordable, mainstream rental housing with
the supportive services needed to help people with disabilities
access and maintain stable housing in the community. This model
is a nationally recognized, cost-effective model for preventing
and ending homelessness and unnecessary institutionalization
among low-income people with serious, long-term disabilities
including mental illness, developmental disabilities, physical
disabilities, substance use disorders, chronic health
conditions like HIV/Aids, and chronic conditions and frailty
associated with aging.
Thank you for the opportunity to testify today.
\1\ PricewaterhouseCoopers, ``Report on Louisiana
Healthcare Delivery and Financing System,'' 2006.
\2\ Families USA, ``Premiums Versus Paychecks: A Growing
Burden for Louisiana's Workers,'' December 2006.
\3\ S.F. Jencks, et al, ``Change in the Quality of Care
Delivered to Medicare Beneficiaries,'' JAMA, 2003.
\4\ Kaiser Family Foundation, State Health Facts--
Louisiana, available at: www.statehealthfacts.org (accessed
March 9, 2007).
\5\ Jencks
\6\ J.R. Graham, ``Don't blame the uninsured,'' Chicago
Tribune, March 2007.
\7\ LSU-HCSD, ``LSU-HCSD Fiscal Year 2005-2006 Utilization
Report,'' May 2006.
\8\ Kaiser Family Foundation, State Health Facts--
Louisiana, available at: www.statehealthfacts.org (accessed
March 9, 2007).
\9\ PricewaterhouseCoopers, ``Report on Louisiana
Healthcare Delivery and Financing System,'' 2006.
----------
Testimony of Cathi Fontenot, M.D.
I would first like to thank members of the subcommittee,
including Chairman Stupak and Ranking Member Whitfield, who
have taken time out of your busy schedules to travel to New
Orleans to witness first hand the destruction wrought by
Hurricane Katrina. Thank you for your attention and for this
opportunity to share our current state of affairs and plans for
the future to support the health care infrastructure in New
Orleans.
I am medical director of the Medical Center of Louisiana
at New Orleans (MCLNO), which is comprised of both Charity and
University Hospitals. MCLNO is part of a State-wide system of
public hospitals and clinics with a principal mission to
provide access to care for the uninsured. MCLNO and LSU's other
hospitals also play an integral role in health care education
in Louisiana, housing the vast majority of residency training
slots in the State. The strong linkage of graduate medical
education and care for the uninsured has been a signal feature
of Lousiana's health policy for many years.
Prior to August 29, 2005, MCLNO provided approximately
270,000 outpatient clinic visits which spanned primary care to
specialties, such as nerve surgery and cardiothoracic surgery.
It housed one of the largest HIV outpatient clinics in the
country and provided 130,000 outpatient emergency room visits.
It was one of only two Level 1 Trauma Centers in the State of
Louisiana, the other being in the northern part of the State in
Shreveport, and served as a primary training site for both LSU
and Tulane Schools of Medicine. In addition to future
physicians, the Medical Center was responsible for training
multiple other health care providers, including nurses and
allied health providers such as physical therapists,
occupational therapists and respiratory therapists. The Medical
Center had a capacity of about 550 beds, including almost 100
psychiatric beds, with occupancy that hovered between 90
percent to 100 percent. You will rarely see such a full census
in any hospital, except in urban public hospitals.
The storm effectively destroyed both MCLNO facilities. The
loss of Charity and University Hospitals has been devastating
to the community. The current status of health care
infrastructure in New Orleans is tenuous and critically ill.
Although we were able to temporarily re-open a portion of
University Hospital, restoring approximately 180 inpatient
beds, the total number of beds in New Orleans is less than half
of pre-Katrina numbers. The population loss, while high within
New Orleans city limits, is actually close to pre-Katrina
levels in the metropolitan area overall. Many have simply
relocated to higher ground but remain in the market. Sicker
patients, who in many cases have lost their health care
providers, present to our emergency rooms with uncontrolled
disease processes due to lack of primary care and access to
medications. Because of the loss of clinic space and cancer
providers, patients who present to our hospital with cancer and
no health insurance have no choice but to travel 60 miles to a
rural LSU hospital for their chemotherapy or radiation
treatments and back 60 miles home while weak and miserable (and
that's assuming they have transportation).
The status of behavioral health is even more dismal with
limited outpatient and inpatient services in the greater New
Orleans area. Emergency rooms across the city are bearing the
brunt of this shortage with anywhere from 10 to 20 psychiatric
patients occupying acute emergency beds on any given day. In
our emergency room alone there are days when half of our
available Emergency Department beds are occupied by psychiatric
patients because there are no inpatient beds available for
them. This situation is unsafe and certainly not in the best
interest of the patients or our employees. It also results in a
major obstacle to Emergency Department through-put for acute
care. Local emergency rooms are already overwhelmed with
patients who seek primary care inappropriately through the
Emergency Department because of loss of health care providers
in the area, and the addition of behavioral health patients to
this mix is simply not good medicine.
Solutions to the health care crisis in New Orleans are
being developed but are constrained by availability of space
and health care providers (both primary care and specialty
providers). A critical component of the effort to restore
health care services involves establishing and strengthening a
network of neighborhood clinics. MCLNO has continued our
collaborative coalition with the group of primary care clinics
known as PATH, Partners for Access to Healthcare for the
Uninsured, where we serve as the major hospital partner and
provide hospital services as well as specialty access. It is
this sort of collaborative effort that can be a real
opportunity to accomplish health care reform as we go forward.
Additionally, the plan for the Medical Center includes
establishment of community primary care clinics in temporary
facilities so that primary care can be delivered in communities
where the basic principles of prevention and disease management
are best delivered. One of the major challenges for health care
providers in the New Orleans region is the lack of access to
specialty care. We anticipate that at least to some degree, we
can maximize the use of the limited specialty care available by
utilizing telemedicine technology and becoming more efficient
at directing patients to the right place at the right time for
the right reason. Additionally, a shared electronic record is
critical to such a network of providers in order to share
information and eliminate costly duplication of effort.
We look forward to continuing our work with other safety
net providers because such a coalition is crucial to real
health care reform and necessary for institution of a new model
of health care in the region.
Thank you for the opportunity to share our information
with you today.
----------
Testimony of Thomas Koehl
Chairman Stupak and distinguished members of Congress and
guests. Thank you for the opportunity to speak to you today.
My name is Thomas Koehl and I work for Operation Blessing,
a humanitarian relief organization that responds to both
domestic and international disasters. Among other activities,
Operation Blessing provides a free medical and dental clinic as
well as a pharmacy in New Orleans. We presently see 75 to 100
patients a day with a staff of volunteer doctors, nurse
practitioners, and physicians assistants. In the past 11 months
we have provided healthcare to over 15,000 patients and
dispensed 25,000 free prescriptions to the residents of this
stricken city.
They were pulled from roof tops, they waded in water, and
spent days sweltering in the heat on highway overpasses and in
the superdome. They are a never before seen American, over
100,000 newly made poor, hopeless, homeless and marginalized.
Our task--yours and mine--is to relieve their suffering.
When Katrina struck, it washed away people's homes, jobs
and health insurance, but not their high blood pressure,
diabetes, and other chronic illnesses.
The need for healthcare is so great that our patients begin
standing in line at three and four o'clock in the morning every
week day in order to see a healthcare provider. Grandmothers,
single mothers with sick children, entire families sleeping in
the cold to wait to see a doctor. They are uninsured, working
for employers that do not provide benefits, and not old enough
to qualify for Medicare or not accepted by the States' Medicaid
program.
Operation Blessing recently partnered with Remote Area
Medical, International Medical Alliance, the New Orleans Health
Department and the LA Department of Health and Hospitals to
host Medical Recovery Week for the greater New Orleans Area.
On the first morning of this event I met Mike in our triage
area. He made his way though a maze of tents, concentrating on
staying warm and keeping his place in line. He was one of
hundreds who had arrived in the frigid pre dawn hours in the
hopes of seeing a doctor. Mike had been in line since 10 pm the
night before. I asked Mike why he was there and he said, ``I
need insulin, I have been out for months and haven't found
anyone that could help.''
Like thousands of returning hurricane evacuees, Mike had
returned to a city where health care was limited and the
majority of residents are now uninsured. ``This was a new
reality check for me,'' Mike said. ``My insurance is gone, my
job is gone, and my home is gone.''
On this day, however, he along with nearly 600 other
patients received free medical care during Operation Blessing's
Medical Recovery Week.
More than 400 doctors, dentists and nurses flew in from
across the country to volunteer for the event, providing more
than 9,000 medical services to more then 3,000 patients by the
week's end. Services included dental work; eye exams and
glasses; primary healthcare; OBGYN services, diabetic care,
pediatrics and cardiology.
To accommodate the influx of patients, we set up 20,000
square feet of tent space to serve as additional exam rooms
outside the Operation Blessing medical and dental clinics--
which have been providing free medical care to more than 15,000
Katrina victims since April 3, 2006.
This was simply a larger version of what we do everyday in
New Orleans. For Mike, help was as simple as receiving a new
meter to test his blood sugar and several vials of insulin.
It's not uncommon day-after-day to hear people sit and cry
and say, I worked across the street at the hospital 24 years. I
had insurance, I had retirement, and its gone. The population
that we are serving is not just those who were poor before
Katrina, but tens of thousands of newly-made poor . . . people
who had jobs, cars, homes, and health insurance.
Our patients still, 18 months after Katrina, get in line
before daylight every weekday to receive healthcare. Over 50
percent of these patients have High Blood Pressure and a third
of those are in crisis when they arrive at our door. 26 percent
of our patients have diabetes and many blood sugars are so high
when they walk through our door that they cannot be measured.
We still see two to three patients a week that have not had
their insulin since Katrina and have just heard about our
clinic.
These citizens are not what you would classically think of
when you think of indigent patients. These citizens just 18
months ago owned their own homes, worked fulltime, went to the
children's band performances and volunteered in their
community. They were people just like your neighbors. People
you would have invited to your home for dinner.
Would you feel comfortable if your neighbors had to stand
in line all night in the cold to be seen by a doctor? Or be
sent to a hospital and have to wait in an ambulance for 4 hours
before they can be seen in the emergency room. The question
then is who is our neighbor. Is it just the family whose grass
meets ours or should we be concerned about those Americans that
we have not yet met.
This population is our modern day Job. They have lost loved
ones, their homes, their cars, their jobs, and their insurance.
We have 127,000 uninsured residents in the city of New Orleans.
They see others profiting from a disaster in which they lost
everything, including their faith in a system which had
promised them health insurance, a pension and, most
importantly, protection.
Today the mortality rate in New Orleans is 48 percent
higher per capita then it was before Katrina. I am not talking
about traumatic injury but death caused by heart attack,
diabetes, and stroke. The infant mortality rate in New Orleans
is five times higher than it was before the storm. The level of
depression is present at rates never before seen in the United
States of America. The depression and stress act to worsen and
exacerbate individual healthcare issues and disease processes.
We are here to discuss what needs to be done going forward.
Build a system where it is easier for non-profit agencies
to operate in disaster stricken areas. Operation Blessing can
provide its own infrastructure, but not all non-profits are
able to provide buildings and appropriate utilities so they can
care for the victims of disaster.
Build a system that encourages for profit providers to
return to the region, where ``the dollars follow the patient,''
where the uninsured have choices and can seek care in private
health care facilities and those doctor's offices and hospitals
are reimbursed for that care. The charity hospitals would have
to compete with private hospitals to survive and would raise
the overall level of patient care in the region.
Among the recommendations being considered to improve
primary and preventive care are technology initiatives to track
a person's medical history and to create community clinics,
health centers and other neighborhood facilities to coordinate
care for those who depend on the State for services. The
community clinics would refer patients to specialists, manage
disease care and provide a consistent system for tracking care.
Please remember that everything that is needed by the city
of New Orleans is also needed by the healthcare system that you
seek to rebuild. Infrastructure such as housing, schools for
the doctors and nurses children, utilities, and people with the
economic ability to pay for the service that is being offered.
All of these are necessary for a sustainable healthcare system.
Since April 3, 2006, Operation Blessing has provided free
medical and dental services to more than 15,000 residents
devastated by Hurricane Katrina and filled over 25,000
prescriptions free-of-charge. We can only do this by partnering
with other agencies and with the financial support of our
donors. I would like to thank all who have made it possible for
Operation Blessing to care for the residents of New Orleans. We
are truly grateful for the opportunity to serve.
----------
Statement of Robert E. Lynch, M.D.
Mr. Chairman and members of the committee, I want to start
by thanking you for the universal support the United States
Congress has given to the Department of Veterans Affairs (VA)
in its rebuilding and recovery efforts not only in southeastern
Louisiana but also the entire Gulf Coast region. Through that
support, our veterans and the VA employees living along the
Gulf Coast continue to make great strides along the road to
recovery.
Hurricanes Katrina and Rita challenged our country with
two of its greatest natural disasters. While Hurricane Rita did
little permanent damage to VA's infrastructure, Hurricane
Katrina, on the other hand, produced unprecedented damage to
its medical center in New Orleans. Our medical center, the
community we serve, and the homes of veterans and employees
sustained destruction on an monumental scale. Today I will
describe our ongoing and planned health care restoration
efforts in New Orleans.
I will speak first to VA health care recovery activities
and its future plans in New Orleans. Next, I will address the
Memorandum of Understanding that was signed between VA and the
Louisiana State University (LSU) System and actions associated
with it. Finally, I will discuss VA's relationship with LSU as
the State of Louisiana progresses in its analysis of State
health care reform.
New Orleans Recovery Activities and Future Plans
Forty-eight hours following Hurricane Katrina's landfall,
as quickly as weather conditions permitted, a VA damage
assessment team was dispatched to the Gulf Region to survey VA
facilities at New Orleans, LA; Biloxi, MS; and Gulfport, MS. At
New Orleans, the team found that the VA facility initially
weathered the storm with minimal damage. However, following the
hurricane, water from the breached levees flooded the entire
medical district and the medical center. Flooding of the
basement and sub-basement in the main building of the VA
Medical Center (VAMC) rendered it inoperable as these areas
housed the facility's major electrical, mechanical, and
dietetics equipment. The medical center's long standing
academic partner, the Louisiana State University Health Care
Services Division at Charity and University Hospital, sustained
similar types of damage. While University Hospital has re-
opened, Charity Hospital is permanently closed.
In the immediate aftermath of Hurricane Katrina, VA's
commitment to the Gulf Coast Region veterans remained
steadfast. VA deployed a system of 12 ``mobile clinics,'' in
coordination with local authorities, to provide urgent and
emergent care to include first aid, immunizations, and
prescriptions. Specifically in Louisiana, mobile clinics
provided care at Baton Rouge, Hammond, Jennings, Kinder,
Lafayette, Lake Charles, LaPlace, and Slidell. VA mobile
clinics treated 5,000 veterans and 11,000 non-veterans in the
aftermath of Hurricanes Katrina and Rita.
To address the health care of veterans in the greater New
Orleans area, VA expanded the capacity of its existing
Community Based Outpatient Clinic (CBOC) in Baton Rouge. We
converted the ninth and tenth floors of the medical center,
formerly the nursing home in New Orleans into exam rooms and
began offering primary care services there in December 2005.
Three months later in March 2006 limited specialty care clinic
services were added to those units. Temporary facilities in
LaPlace (St. John's Parish), and Slidell were leased as
alternate care sites. Tents were erected in Hammond to provide
basic services.
With the support of Congress, VA was authorized to
accelerate the activation of CBOCs proposed under CARES and
opened a permanent clinic in Hammond in August 2006. We remain
in leased space in Slidell and plan to construct a permanent
clinic there in three to five years. The St. John CBOC is
anticipated to open in October 2007.
Basic outpatient mental health services are provided at
each of the clinic locations. Currently, inpatient mental
health care is coordinated with the Alexandria (LA) VA Medical
Center. Dental clinic services were re-established in April
2006 by leasing space in Mandeville, Louisiana. In Baton Rouge,
we leased the old CBOC building in 2006 and are using that
facility to house the medical center's clinical laboratory, as
well as select administrative support functions.
As a result of these actions, the Southeast Louisiana
Veterans Health Care System (SLVHCS), formerly known as the New
Orleans VA Medical Center, served over 29,000 veterans in
fiscal year 2006. This is 72 percent of the previous year's
workload. Fiscal year 2007 workload to date is growing at an
annualized rate of ten percent over last year and is expected
to increase as housing is restocked in the area.
To help our staff and support the community, VA worked
with its academic affiliates, The Tulane University School of
Medicine and the LSU School of Medicine, to place VA faculty,
medical staff/residents, and student trainees at VAMCs
throughout our VISN 16 Network.
With the VA's inpatient units shut down, 102 medical
center employees that included nurses, health technicians,
medical support assistants, operating room technicians,
certified registered nurse anesthetists, and radiology
technologists were temporarily deployed in July 2006 under a
Federal Emergency Management Agency (FEMA) task order to
provide critically needed staff support to local health care
institutions.
In terms of future VA services in New Orleans, we continue
to explore our long-term options for re-establishing surgical
capabilities and inpatient services in New Orleans. In the
interim, these services are coordinated through sister VA
medical centers in Louisiana, Mississippi, and Texas, as well
as through selective referrals to community hospitals in the
New Orleans area at VA expense. We are actively pursuing
options for expanding outpatient mental health services to meet
current and future veteran's needs.
Projects for the re-establishment of radiology and
outpatient pharmacy services on the grounds of the old medical
center campus are underway and expected to be completed later
this calendar year.
In preparation for the construction of a replacement
medical center, VA has initiated its space planning process.
Interviews of architecture and engineering firms to design the
new facility are complete. A selection is expected this spring.
The replacement medical center is expected to provide acute
medical, surgical, mental health and tertiary care services, as
well as long-term care.
Memorandum of Understanding between VA and LSU
As required in Public Law 109-148, VA compiled and
presented its long-term plans for the construction of a
replacement hospital in New Orleans in its February 2006,
``Report to Congress on Plans for Re-establishing a VA Medical
Center in New Orleans.' In that report, VA identified its
principal objectives regarding the New Orleans area as being
not only to restore services to veterans in the most cost
effective manner, but also to assist in the restoration of
health care and medical education in New Orleans. Recognizing
the successful history for sharing and collaboration between VA
and the LSU Health Care Services Division, as well as the
potential for future efficiencies, the report concluded that
construction of facilities on a single campus with support
services shared with LSU was the preferred option.
As a result of the ``Report to Congress,'' VA and LSU
leadership signed a Memorandum of Understanding (MOU) agreeing
to jointly study state-of-the-art health care delivery options
in New Orleans. This MOU established the foundation for
developing a collaborative approach to operating a replacement
facility. From that a group of experts from both organizations,
called the Collaborative Opportunities Study Group (COSG) was
charged with determining if any mutually beneficial sharing
could occur between the two organizations. In the group's June
2006 report delivered to the former VA's Under Secretary for
Health, it concluded that both organizations could leverage
their strengths, provide significant operating efficiencies,
and allow us to better serve our beneficiaries. Congress
subsequently authorized VA to pursue the project to replace the
New Orleans facility as a collaborative effort consistent with
the COSG report.
In September 2006, the Collaborative Opportunities
Planning Group (COPG) was established to develop an operational
plan for sharing between the two organizations based on the
foundation work of the COSG. The COPG is co-led by VA and LSU
representatives. Representatives of the Tulane University
School of Medicine and the State of Louisiana Division of
Administration are also part of this group and its planning
discussions.
A critical component of the charge of the COPG is to
determine if the proposed sharing options identified in the
original COSG report are viable and if they are, to begin the
work of developing timelines and formulating the framework for
space planning and design for a joint replacement facility. To
date the COPG has made significant progress by reviewing
literally dozens of clinical and administrative functions to
determine if the function would best be provided via a sharing
arrangement between VA and LSU or independently owned and
operated by both entities. The COPG's final report is to be
presented by September 30, 2007.
VA's Future Relationship with LSU
The VA remains excited about its MOU with LSU in the
context of health care redesign in Louisiana. We support all of
the principles behind it. At the same time, health care
redesign seems to face some obstacles and delays in Louisiana.
Because of this, we are committed to exercising due diligence
to our veteran beneficiaries and to the tax payers, and are
concurrently exploring other options for initiating
reconstruction of the Southeast Louisiana Veterans Health Care
System's medical center within Southeast Louisiana. In
furtherance of this, we plan to begin a site search to identify
alternative locations in the near future while we continue to
work with LSU on our collaborative plans.
Mr. Chairman, we consider the committee and the Louisiana
delegation to be partners with VA in seeing that southeast
Louisiana veterans continue to receive the high quality health
care that they have come to expect and deserve.
Congress appropriated to VA $1.2 billion in supplemental
funding for recovery and rebuilding efforts. This includes $625
million to replace the New Orleans Medical Center. These
efforts have enabled VA to provide timely access to care in New
Orleans' surrounding communities through strategies such as
leasing medical office space and establishing three new CBOCs.
The commitment to uncompromised excellence in health care
and service to the community has resulted in bodies such as the
Collaborative Opportunities Planning Group rethinking
previously established relationships and identifying new
strategies to improve operational efficiency and quality of
care in areas such as academic medicine, use of electronic
medical records, subspecialty care, and joint emergency
preparedness planning. VA's construction of its new medical
center will be an important part of improving healthcare
services for veterans in New Orleans.
Thank you for the opportunity to be here today. I will be
pleased to answer any questions you may have.
[GRAPHIC] [TIFF OMITTED] 36572.012
[GRAPHIC] [TIFF OMITTED] 36572.013
[GRAPHIC] [TIFF OMITTED] 36572.014
Testimony of Alan M. Miller, Ph.D, M.D.
Mr. Chairman and members of the committee: Thank you for
the opportunity to speak to you all about the state of health
care in the New Orleans region eighteen months after Katrina
and about Tulane University's role in the recovery. Since
Hurricane Katrina devastated our city--and our healthcare
system--in August 2005, we've seen enormous progress in some
areas despite almost overwhelming challenges. In other,
critical areas, we have seen shockingly little progress
resulting in a situation that now appears to pit the Federal
Government against the State of Louisiana. Such an impasse will
only make reform more difficult and the ensuing delays in the
decision making process could threaten the very existence of
our medical training programs. As you can see, we still have a
long way to go before health care for the citizens of our
region approaches anything near what we used to deem
``normal.''
First, I want to thank members of the committee for your
support for the region over the last eighteen months. Many of
you have been to New Orleans and have seen firsthand both the
devastation and the progress. For those of you who have who
have not yet been to the region, I urge you to come at your
earliest opportunity. Through efforts such as this hearing and
the spotlight it continues to shine on the challenges of our
region, it is my hope we can move toward a system that provides
equal access to quality care for all our citizens while also
training a qualified and committed physician workforce that
will assure the future of care in our State and region. At the
end of the day, this is all about access to care for all our
citizens, now and in the future.
My institution is somewhat different from those of my
colleagues on this panel. I represent an institution of higher
education whose mission includes not only providing healthcare
to the citizens of the region but also training future
physicians. Today, I'd like to focus my comments on four key
areas:
Tulane University's efforts in the immediate
aftermath of the storm;
Our continuing efforts to train the future
physicians and provide clinical care;
The immediate needs for retention of a qualified
workforce; and,
Long-term needs associated with maintaining and
growing an adequate physician workforce to meet patient needs.
Tulane University: After the Storm
The past year and a half has been extremely challenging for
everyone in New Orleans, but especially for those of us trying
to assess healthcare needs, rebuild a broken healthcare system,
continue to provide care for all New Orleanians who need it,
and continue to train young physicians. The Tulane University
Health Sciences Center suffered losses of greater than $200
million in property damage, lost research assets and lost
revenue. Through the storm and since, despite seemingly
overwhelming challenges Tulane--the largest employer in Orleans
Parish--has continued to do exactly what it has done since its
creation in 1834: providing health care, educating physicians,
and advancing medical knowledge through research and discovery
in New Orleans and Louisiana. Over the next few minutes I would
like to update you on Tulane's current activities, our place in
the recovery of health care in the New Orleans area, and our
concerns for the future.
When Hurricane Katrina struck in August 2005 it left our
620 medical students, 520 residents and most of our faculty and
staff scattered across the country. Our IT system was
inoperable, all communications systems had failed and our
student and personnel records were trapped in flooded buildings
in New Orleans. At that point Tulane University consisted of 30
people working out of a Houston hotel suite.
What was accomplished in the weeks after Katrina is nothing
short of remarkable. Faced with a self-imposed target date of
September 26 to resume classes and training for our medical
students and residents, in three short weeks of long workdays
we set up a medical school at the Baylor College of Medicine
with our displaced students using Tulane's curriculum and
taught by Tulane faculty. We received critical life support
from, and will always be indebted to, four Texas institutions
that formed the South Texas Alliance of Academic Health
Centers: Baylor College of Medicine, The University of Texas
Medical School at Houston, Texas A&M University System Health
Science Center College of Medicine and the University of Texas
Medical Branch at Galveston.
At the same time, back in New Orleans, a small but
determined group of physicians and residents remained steadfast
in their mission to provide care to those who remained in our
devastated city--both citizens and first-responders. Tulane
University provided care at six sites, 7 days a week in Orleans
Parish, seeing approximately 500 patients per day and becoming
the largest ambulatory care provider in the parish. In October
2005, Tulane faculty and residents began to concentrate
activities at Covenant House on Rampart Street. Since that
time, more than 8,000 adult patients have been seen and
currently 45 patients a day are being cared for. A separate
pediatric drop-in clinic at the same site has seen close to
1,500 babies, children and young adults. At the drop-in center
annex, mental health services have been provided to more than
141 clients for 536 visits since July.
In addition, Tulane Pediatrics, in partnership with the
Children's Health Fund, has operated a Mobile Medical Unit
treating patients at a variety of locations in New Orleans and
in St. Bernard Parish. Since January, 850 adults and 1,000
children have received primary care services from Tulane
Pediatric and Med/Peds faculty and residents in the mobile
unit.
Training Our Future Physicians
Well-educated and trained physicians are essential elements
in assuring access to quality healthcare services not only in
New Orleans but throughout our country. Tulane's healthcare
mission and medical education mission are intimately
intertwined. Teaching faculty, supervising medical residents,
provide a large portion of the care for most there. Today, a
total of 327 Tulane residents and fellows are being trained in
40 programs, approximately 63 percent of the number being
trained pre Katrina. Each year that Tulane and the other major
medical school in New Orleans, LSU, train a reduced numbers of
residents, will have long-term implications for the supply of
physicians in Louisiana.
In the 2005-06 academic year Tulane and LSU required
special waivers from the Centers for Medicare & Medicaid
services (CMS) in order to allow their residents to continue
their training in multiple hospitals throughout Louisiana as
well as outside of the State. In order for this to occur,
protracted negotiations between the medical schools, the
hospitals and CMS occurred. In the event of another major
disaster where major teaching hospitals may be forced to close,
a better solution is needed to deal with the disruption in
medical training. Despite the waivers granted by CMS, Tulane
still absorbed unreimbursed costs of approximately $3 million
related to graduate medical education (GME) for the 2005-06
academic year. Even with reduced numbers of residents and
redistribution of residents to new locations, we anticipate an
additional loss of $2 million for the current year. It is not a
financial burden we are able to carry much longer.
In addition to GME costs, with the city's public hospitals
down, the burden of care for the uninsured has been assumed by
the city's private hospitals and private physicians. The
State's Medicaid Disproportionate Share (DSH) payment system
has historically been directed to the State's safety net
hospital system. With the closure of the largest components of
that system there was a major gap in funding the care of those
patients. The Federal Government has taken steps to assist
hospitals in the care of this patient population. In March
2006, CMS allocated $384 million for the uncompensated care
pool to help hospitals that were caring for the uninsured.
While appreciated, these funds have not been sufficient to
compensate hospitals, and none of these funds were allocated
directly to physicians and other healthcare providers. Tulane
faculty physicians will have provided $6.8 million in
uncompensated patient care between September 2005 and June
2007. Tulane University has been able to retain the majority of
its physician faculty by guaranteeing salary through the end of
June 2007--in effect, a private nonprofit educational
institution has been using its dramatically impaired and
limited financial resources to help underwrite healthcare in
the State and help preserve the healthcare workforce. Having
suffered losses of approximately $500 million in Katrina--$300
million in addition to the losses at the Health Sciences
Center--Tulane cannot continue to do this and survive.
If we are to preserve the physician workforce both at our
teaching institutions and in the general medical community,
there needs to be immediate funding for providing care to our
citizens. If this does not occur, New Orleans physicians will
continue to abandon their practices and leave the community,
and we will not be able to recruit replacements. Those that
suffer will be the patients who cannot find adequate care. It
has been calculated that approximately $30 million per year is
needed to provide basic reimbursement to physicians for
uncompensated care. A mechanism to providing funding directly
to providers must be considered in order to reimburse
physicians for care provided in the past 18 months and for
ongoing support of care.
Another important component of both the patient care and
graduate medical education missions of our medical schools has
been the New Orleans Veteran's Affairs Hospital (VA). Pre-
Katrina, Tulane faculty physicians provided approximately 70
percent of the patient care at the VA and 100 resident
physicians were on rotation at that facility. Since Katrina the
hospital has remained closed, with inpatients being sent to
other VA facilities, predominantly out of State. Outpatient
clinics have reopened and visits are up to 75 percent of the
pre-storm numbers. Currently, the VA is supporting 26 Tulane
residents who are involved in the outpatient care. In order to
provide optimal care to Louisiana's veteran population, keep
them close to home and to return another important piece to the
medical education pie it is essential to re-establish a VA
hospital in downtown New Orleans. It is critical for Veterans
that this facility be easily accessible from main
transportation arteries and to the Tulane and LSU training
programs. The VA must also be proximal to the medical schools
so that the highly skilled faculty of those schools are
available to provide state-of-the-art care, and foster the
training of the physician workforce that is so important to the
long-term future of health care in the region. It is also
important for the economic development of downtown New Orleans
that the VA be part of the growth of the Biomedical District.
Tulane has been an integral partner with the New Orleans VA and
desires to remain such in the facility's re-establishment.
Immediate needs: a Stable Physician Workforce
According to the Louisiana Department of Health and
Hospitals there were 617 primary-care physicians in New Orleans
prior to Katrina. By April 2006, that number had dropped to
140, a decrease of 77 percent. In July 2006, Blue Cross Blue
Shield of Louisiana reported a 51 percent reduction in the
total number of physicians filing claims in Region I. nearly
all of this reduction--96 percent--was from Orleans Parish. The
loss of additional clinical faculty at Tulane as well as LSU
will not only decreases the available current physician
workforce, but reduces the clinical teaching faculty needed to
teach the next generation of physicians for the region and the
State.
In addition to laying the groundwork for the future, there
must be an immediate focus on the future of our Graduate
Medical Education programs. According to a report prepared by
the healthcare redesign collaborative, ``The medical workforce
situation has quantifiably deteriorated, but it could get worse
before it gets better unless the State's internal engine of
physician supply is rebuilt and modified for the new demands of
a redesigned healthcare system. That engine is graduate medical
education (GME), a rich source of newly minted physicians in
any State but particularly in Louisiana. Among the States,
Louisiana ranked No. 2 in the number of its doctors having
trained within the State, and No. 17 in retention of
residents.''
In a sense, this is a long-term issue, but it requires
immediate attention. I would request that Congress consider a
time-limited grant program that would provide incentives to
encourage clinical faculty candidates to come to one of the
teaching institutions in the Gulf Region. Recently, $15 million
was made available for recruitment and retention of primary-
care physicians. The Louisiana Department of Health and
Hospitals is currently working on the details of how those
funds will be distributed. But those funds do not apply to
highly trained specialists needed to staff academic medical
centers and training programs and provide care and educate the
future physician work force. We would request that additional
funding be made available for recruitment of qualified clinical
faculty to the region's institutions, including loan
forgiveness, relocation and bridge funding to allow adequate
time for physicians to establish a practice.
Long-term needs: Rethinking Graduate Medical Education & Establishing a
Stable Healthcare System
As stated earlier, the gridlock in which we now find
ourselves is destructive in the short and long term for
systems, hospitals, medical schools and most importantly the
public we serve. The time has come for all parties to set aside
their differences, share vital information and data and have an
objective party lead constructive negotiations. As a partner in
MCLNO and as a member of the administrative board with
legislatively madated fiduciary responsibility, Tulane would
welcome direct involvement in the current business plan
development process for the proposed new facility. To this
point, we have not yet been asked to participate nor have we
been privy to any information beyond what was presented in
November, 2006.
The experience of Katrina revealed a major flaw in the way
we fund Graduate Medical Education in this country, at least
under the circumstances of a major disaster that results in the
closure of teaching hospitals. The slots in which residents
train are allocated to hospitals by CMS, and the reimbursement
for the educational efforts of those residents is paid by CMS
to those hospitals. In many cases, like those of Tulane and
LSU, the responsibility for training those residents is held by
major medical schools. To provide the optimal educational
experience these medical schools will rotate residents through
a variety of hospitals. In order to provide the residents with
a stable pay source the medical schools function as a common
paymaster, paying the residents directly and receiving
reimbursement from the hospitals.
When Katrina hit and MCLNO and other training hospitals
closed, the medical schools were left with the responsibility
of guaranteeing the resident training and payment of salaries,
but it left us unable to seek reimbursement from closed
hospitals. Other hospitals came to the fore and provided
training opportunities, but in most cases were unable to
provide payment to the medical schools, which continued to pay
the salaries of all the residents. Temporary waivers were
finally received from CMS that allowed the residents to
continue their training, but these did not go far enough to
protect the medical schools, and created a complex system of
documentation on the already strained systems of the medical
schools and the closed hospitals. To simply comply with the
burdensome paperwork required, Tulane was forced to hire
outside counsel to navigate the process and complete the
documentation. Some look at residents as movable parts that can
be rearranged to maximize CMS reimbursement. This is far from
the truth, issues of program interrelationship, critical mass
and quality of educational experience must be considered or
accreditation will be at risk.
This system must be reviewed and revised before another
disaster hits one of our nation's training institutions, be it
flood, fire, earthquake or an act of terrorism. In Louisiana,
medical schools must have greater flexibility and control over
slots not being used by the parent hospitals due to full or
partial closure. Current arrangements for the redistribution of
closed or partially closed hospitals--unused slots require the
hospital to enter into affiliation agreements annually with the
``receiving'' hospital, and then for the medical schools to
reach financial agreements with those receiving hospitals to
repay the resident costs of the school. This arrangement puts
the resident, the medical school and the receiving hospital at
risk if the ``home'' hospital changes those arrangements or
fails to execute affiliation agreements. For the protection of
all, but most critically that of the trainee, medical schools
must have greater control over both training and funding when a
disaster results in total or near total closure of a teaching
hospital. We now face a system that is uncertain and the
instability created by the absence of our traditional training
sites requires that we reconsider how these slots are
distributed and by whom.
Tulane University and all the groups represented here today
have many challenges still to overcome. But with the support of
the American people and through our public leaders such as
those of you on this committee, we will recover. And through
our recovery we will provide our citizens with the best
possible health care and a highly trained and committed
workforce that will be a cornerstone to the long-term
revitalization of the city of New Orleans.
Specifically, we ask your consideration in taking the
following actions:
We request this committee consider convening a hearing to
specifically deal with the issues surrounding Graduate Medical
Education and possible solutions to preserve the quality of our
training programs in the State. In addition, Tulane would like
to host a panel that would include representatives from the
committee, area medical schools and hospitals, as well as CMS
and the AAMC to re-evaluate how resident training, and payment
is dealt with in a disaster or other circumstances when the
home hospital is either completely or partially closed,
disrupting the training of those residents.
Provide funding for reimbursement of physicians for
providing care to the uninsured. It is estimated that $30
million per year is needed.
Create funding to assist medical teaching institutions in
the Gulf Coast region recruit qualified specialty teaching
faculty to train the future physician workforce.
Support the re-establishment of the New Orleans VA
Hospital in downtown New Orleans, in proximity to the medical
schools to allow for optimal patient care, medical training,
and economic development of the New Orleans Biomedical
District.
While it is our job to create a healthcare system that will
provide the citizens of New Orleans and the State of Louisiana
with highest quality care, I would ask that you strongly
encourage all of the parties to consider an objective party to
lead us to consensus and that we mutually agree upon a deadline
for making the broader decisions regarding moving forward. Once
again, I thank you for allowing me to speak to members of this
committee today. With your help, we will continue to bring
health care in our city and region not just back to where it
was, but into an even better future.
----------
Testimony of Gary Muller
Mr. Chairman and members of the committee:
Thank you for inviting me to testify on behalf of West
Jefferson Medical Center. I am grateful that the committee has
expressed a continued interest in the worsening state of the
healthcare system in the New Orleans region. I also would like
to take this opportunity to thank Co-Chair, Congressman
Melancon, for your dedication and hard work on behalf of the
people of Louisiana.
West Jefferson Medical Center, located 10 miles 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 was one of three hospitals
that did not close after Hurricane Katrina and is now one of
the eight safety net facilities serving all patients. Pre-
Katrina we were projecting an $8 million profit for 2005. When
I testified before this committee last year we had incurred
operating losses of $30 million I come to you this time with a
heavier burden of $48 million in operating losses. To put it in
health care terms, prior to the storm we were a healthy
patient. Now we are critically ill.
Financial survival has become the top priority for WJMC and
we have focused efforts to explore every regulatory or
legislative mechanism that might assist us. The Post Katrina
story is complex as we embrace challenges continually.
Providers of all types are experiencing significant financial
losses as we struggle to retain health care workers and deliver
care.
Recruiting nurses and physicians has become a near
impossibility and the supply and demand of the entire
healthcare workforce has reached a crisis. Prior to Hurricane
Katrina we spent a total of $2 million annually on agency
nurses. Currently, we are forced to spend $1.1 million each
month, which was $13 million in 2006. It is extremely difficult
to simply have a physician visit our city for the possibility
of working here.
The region's labor and operating expenses have inflated
dramatically without corresponding payment increases. Hospitals
have also experienced a dramatic rise in uncompensated care. I
would like the opportunity to discuss both of these issues with
the committee.
Certain financial adjustments are necessary to maintain
hospital operations in our area.
The 2007 wage index update that was effective as of October
2006 was based on wage data from Medicare cost reports that
began during Federal fiscal year 2003. Thus, there is almost a
three-year lag between the data being used to develop the wage
index and the actual implementation of the wage index that
incorporates the data. Under the CMS methodology for
incorporating changes to the wage index, our wage index will
not begin to reflect the changes that we have experienced in
labor costs until October 2008. We just can't wait that long. I
am requesting that you consider a special wage-index adjustment
for hospitals in the affected area to help offset some of the
losses attributable to the added cost of operating in the post
Katrina environment.
WJMC is a public service district hospital and we are
supportive of the CMS Medicaid Proposed Rule on
Intergovernmental Transfers (IGTs) and Certified Public
Expenditures (CPEs) issued on January 12, 2007. As we
understand the proposed rule, CMS will require States to direct
Federal funds back to governmentally operated healthcare
providers. This certainly seems aligned with how the Federal
Government intended these funds to be used in the first place.
For WJMC, we believe this will result in equitable distribution
of funds to our hospital.
West Jefferson Medical Center has 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
qualify hospitals as eligible recipients of the Community
Disaster Loan Program. With the hard work of our entire
delegation we were successful in securing that funding. That
funding from CDL was vital for our hospital in the few months
following the storm when we incurred substantial financial
losses. Both the House and Senate appear to be on the verge of
Floor action to permit the Forgiveness of CDL loans, which has
been the practice pre-Katrina. I strongly ask for your support
to forgive these loans our hospital is currently obligated to
pay back.
Please be reassured that we have taken all steps possible
to become more cost-effective and efficient in our day-to day
operations. We have implemented an Operations Improvement
Action Plan (OIAP) whereby approximately $8 million of savings
or revenue enhancements have been identified. Most of the cost
savings center on reducing agency nurse costs which included
only two agency nurses pre-Katrina and grew to 92 agency nurses
presently. We have also improved efficiencies (per length of
stay and discharges) so that the emergency room can flow better
with the increase in patient volumes. WJMC also supports two
federally Qualified Health Centers (FQHC) in our service area
to support the medical home model of delivering primary care in
clinics rather than in our emergency room.
Let me take this opportunity to provide you with a snapshot
of our ED situation. One day last week we were overwhelmed with
32 admissions waiting in our emergency department. Simply put,
every available bed in our hospital was occupied and we had 32
admitted patients waiting on stretchers in the hallway of the
emergency department. Our ambulances and paramedics routinely
wait with these patients which takes them off of the streets to
serve other patients in need. Unfortunately, this is quickly
becoming the norm as there are simply not enough staffed beds
in the New Orleans region to care for the volume of patients.
We put a phone call into the Department of Health and Hospitals
expressing this concern. The next day the secretary of the
department, Dr. Fred Cerise, was at our hospital offering
assistance and potential solutions. He has also been helpful
with his support of the Uncompensated Care Cost pool that was
developed at the State level to offset some of our growing
indigent care costs. Nonetheless, the shortage of beds,
particularly psychiatric and acute care beds, is at a critical
point.
I remain optimistic that, as discouraging as our problems
may seem, our issues will eventually be resolved by both
private and public hospitals, community clinic providers,
payors and government officials presenting a united solution in
a new model that will improve care for all citizens of
Louisiana. I have great faith that our Federal leaders will not
abandon us. Together, we can make a difference. Thank you for
your time and interest.
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Testimony of Evangeline Franklin, M.D.
I am Dr. Evangeline Franklin, Director of Clinical Services
and Employee Health for the New Orleans Health Department. To
Chairman and Congressman Bart Stupak, Ranking Member and
Congressman Ed Whitfield and distinguished members and guests
of the Subcommittee on Oversight and Investigations of the
United States House of Representatives Committee on Energy and
Commerce: Thank you for the opportunity to speak with you today
about two health clinics that the New Orleans Department of
Health recently held in the City of New Orleans. Mayor C. Ray
Nagin and members of his administration have sought creative
means of addressing our citizens critical healthcare needs as
we work to recover from the tragedy of Hurricane Katrina and
the subsequent flooding.
Today I would like to describe to you a city, indeed a
region, which continues in health crisis despite the valiant
efforts of our organizations. This crisis results from a
combination of factors. The people of New Orleans face many
challenges, such as the difficulty of returning to rebuild
homes and businesses, the tendency to ignore chronic illness
that these stressful distractions have caused or exacerbated,
and the complexity of the processes to claim insurance proceeds
or funds from the Louisiana Road Home Program, the state
initiative to compensate homeowners for their losses in
Hurricanes Katrina and Rita. All of these are complicated by a
healthcare system that itself is damaged and under stress,
further limiting the access to healthcare that even before
Katrina was not ideal.
In the aftermath of Hurricane Katrina, the population of
the uninsured in New Orleans has expanded from traditionally
uninsured groups to include many who have experienced sudden
loss of benefits. This includes individuals who were laid off
from jobs due to the destruction of their place of employment
or the loss of market or tax base. Many of these people
returned New Orleans following the floods because of personal
or business financial commitments or because they simply wanted
to come home. The composition of our uninsured also includes
persons who cannot speak English and those who cannot secure
health insurance because of their migrant worker status or lack
of the proper immigration documentation. Many of our uninsured
are part of the working poor, who toil daily in their jobs but
are not offered or cannot afford health insurance.
Hurricane Katrina and the subsequent flooding were
responsible for the loss of much of the health care
infrastructure, including hospitals, doctors, medical records
and pharmacies. It also meant that many people lost their
medications, dentures and eyeglasses. This, when coupled with
the physical and psychological hazards of the devastation, has
put patients who were previously stabilized at great risk.
In the past year, was assigned to coordinate two large
scale healthcare events designed to provide medical, dental and
optical services, and to assist in organizing follow-up. By
helping patients regain some control of health problems, the
healthcare community could better manage medical resources such
as emergency room use and admission to hospitals.
Both of these 7-day events were highly successful.
Thousands of patients were able to leave each outdoor event
with a 30-day supply of needed prescriptions, as well as
eyeglasses, dentures, immunizations, PAP tests and information
about where to obtain follow-up medical care. Unfortunately,
this occurred only after they endured long lines, sometimes
waiting all night in cold and rainy weather to be treated on a
first-come, first served basis by volunteers from throughout
the country and local professionals. Typically, capacity for
each day was reached within an hour of opening the
registration. As a result, many who needed care were unable to
receive it and had to be turned away to be seen on another day
or at other locations.
The first of these events was held in February 2006 at the
Audubon Zoo, a location considered by the planning committee to
be an oasis in the middle of destruction. Audubon Zoo made a
significant contribution by allowing us access to their grounds
to set up the clinic locations, by housing volunteers and by
having their employees contribute their time for the seven-day
event.
This event was an immediate success, in large part because
of its location and accessibility to the many patients who did
not have cars. Many came by bus or walked to the event. The zoo
is located in an area of the City which was among the first to
repopulate because of the lower level of damage.
Because of the magnitude of the catastrophe, very few
safety net clinics and pharmacies were available to residents
so soon after the storm. Many weary patients reported that they
were unable to locate their doctors and did not know where to
go to have their prescriptions filled. Others offered poignant
stories about their inability to obtain needed care,
medications and immunizations.Of 5,212 persons who received
care at the Audubon event, 27 were transferred to local
hospitals for emergency care. One of those was a revived
cardiac arrest. This woman was having her cholesterol level
tested during her visit to the Reach 2010 at the Heart of New
Orleans facility when she had what later was determined to be a
heart attack. While she was unable to obtain primary care, she
could be cared for after having a life threatening event. She
is currently doing well.
Others were not so fortunate. One gentleman was given a
diagnosis of metastatic cancer. He had been told at one of the
local private hospitals that he had to pay for his diagnostic
tests before he could receive treatment. He did not have the
required money and was refused treatment. Because Charity
Hospital had not yet reopened, there was no public facility in
the city that could provide cancer care. Further complicating
his situation, this man could not speak English and had no
transportation. Despite these difficulties, we arranged for
this gentleman to go to another facility to receive care.
Many of the volunteers during the week remarked that they
had never seen so many people who were so very sick. In all,
1,313 volunteers treated 5,212 patients during this seven-day
event. In addition, prescriptions were filled at no charge and
social services, including mental health, were made available
for interested patients. Volunteers traveled to New Orleans at
their own expense.
The second event was held a year later in conjunction with
Operation Blessing, a faith-based organization supported by the
Christian Broadcasting Network. Operation Blessing operates a
clinic with medical, dental and pharmaceutical services in
eastern New Orleans. The weeklong Health Recovery Week II was
took place in tents. The New Orleans East location of Operation
Blessing was accessible by car and bus and had become an anchor
by providing free care even before Health Recovery Week II.
This was an ideal location for the second event because the
neighboring communities have shown signs of return and
rebuilding. FEMA trailers placed in front of houses and the
sale and purchase of property for renovation herald the return
of significant resources of the professional and business
community. In addition, citizens from eastern New Orleans were
part of the regular patient population at Operation Blessing.
Because the medical director is fluent in Spanish and
Vietnamese, non-English speaking residents are drawn to this
facility. In addition, this location does not interfere with
the function of clinics and services in the part of New Orleans
where the population has stabilized.
For this event, Operation Blessing invested nearly $500,000
for the cost of supplies, lab work, pharmacy services,
infrastructure improvement, marketing, and food and lodging for
volunteers at their Slidell, Louisiana Command Center.
Even though more medical facilities and safety net clinics
had opened in the intervening year, the story was exactly the
same as before. Fewer patients were treated but only because
there were fewer volunteers who could see them. Again, patients
waited in the cold and the rain and were willing to be seen in
tents for their medical, dental and optical care. And again,
citizens frequently stated that they could not find their
doctors and did not know where to get their medications.
The vast majority of patients seen during the health
intervention week had never been to Operation Blessing. Many
had been referred to obtain services that they could not
receive in their regular clinics. Of the 3,800 patients seen at
this seven-day event, 21 were transferred to local hospitals.
As in the first Health Recovery Week, hundreds were turned away
after the capacity of the event filled within an hour of its
opening. Among those transferred to the hospital, one patient
was experiencing cardiac arrest and, like deja vu, a man with a
terminal cancer told the story of being unable to obtain care.
Many diabetics did not have their medications and many people
were diagnosed for the first time with hypertension and
diabetes. Women who needed preventive care, such as Pap tests,
also were identified. The medical, dental and optical services
provided were valued at $1.1 million.
Again there were many non-English speaking patients who
told of their fear of receiving health care because they might
be identified for deportation.
These events highlight the urgency of our healthcare crisis
in New Orleans and demonstrate that we need assistance to
expand our capacity. When the Governors Emergency Order
permitting health professional volunteers from out of state to
practice in our city is lifted in the next few months, we will
no longer be able to accommodate the medical, dental and
optical volunteers who want to help and whose help we will
still need.
Thank you for your consideration of what I have shared with
you. These events and their large numbers indicate that the
current solutions are insufficient to meet the needs of
returning citizens and the new workforce. Our situation is
urgent and we look forward to working with you.
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Testimony of Patrick J. Quinlan, M.D.
Mr. Chairman, members of the subcommittee, thank you for
this opportunity to appear before the Subcommittee to update
you on the impact of Hurricane Katrina and its aftermath on the
Ochsner Health System. First, I would like to thank the many
Members of Congress, including members of this subcommittee,
who have traveled to the Gulf Coast over the past 19 months to
see for themselves the overwhelming devastation wrought on our
City and our State as a result of the disasters associated with
Hurricanes Katrina and Rita. Your personal presence and
concerns are certainly appreciated by our citizens.
Ochsner Health System is an independent non-profit
organization made up of seven hospitals and thirty-two clinics
employing over 8,400 people. Ochsner is the largest private
employer in Louisiana. Ochsner Medical Center was one of only
three hospitals to keep its doors open despite the ongoing
interruption of its business, during and after Katrina to care
for all patients. We made this decision despite the fact that
physical damage to our facilities caused us to suffer a
significant interruption of our business both during and after
the storm. Since Hurricane Katrina, Ochsner's professionals
have quietly gone about their work of providing high quality
healthcare to everyone--regardless of their ability to pay. We
experienced significant physical damage to our facilities as a
result of Hurricane Katrina. Ochsner has exercised due
diligence to rebuild its property and mitigate the damage done
to its business because of Hurricane Katrina. Nevertheless, we
experienced significant additional costs and lost revenues as a
result of this damage and the consequent interruption of
business. The hospital also had to provide food and shelter for
staff, as well as pay them for long hours at increased
compensation. Ochsner's extensive disaster preparations played
a major role in the ability to mitigate its damages, and to
provide services for patients in the entire region under
emergency conditions. That preparedness ultimately allowed
citizens that evacuated to return home with the assurance that
their healthcare needs could be met.
Hurricane Katrina caused property damage losses of
approximately $23 million to Ochsner facilities, but with the
application of deductibles; only about $11 million is covered
by insurance. FEMA has paid a minimal amount to date. In
addition, business interruption losses caused by Hurricane
Katrina and its property damage have been over $57 million. Our
business interruption deductible, however, is approximately $11
million. We continue to have issues with our primary insurer
with resolving our claim. Total payments from insurance to date
have been only about $23 million.
Currently Ochsner employs over 600 physicians and more than
120 licensed mid-level health providers who receive no payment
for the care of the uninsured. This acts as a significant drain
for our Health System because of lack of funding for both
hospital and Ochsner physicians.
We are one of the largest private non-university based
academic institutions in the country with over 350 residents
and fellows, proven research including bench research,
translational research and clinical trails. In addition, we
provide training for approximately 400 allied health students
and over 700 medical students from LSU and Tulane with little
funding to support this mission. The importance of Ochsner's
graduate medical education program has increased greatly since
Katrina because we are the only fully functional academic
center in the greater New Orleans area. We know that a
significant number of physicians locate to practice where they
train, so we are training the next generation of medical
doctors for the area.
The sad reality is that we are bleeding red ink as a result
of holding this fragile healthcare system and medical education
system together and are caught in the middle of excessive
bureaucracy in both the public and private sectors. Simply put,
well-intended money to help us as providers is not reaching us
on a timely basis. And when that money does reach us it is
insufficient to meet our needs.
Despite our efforts at retention we lost over 2000
employees and more than 100 physicians during and after the
storm who decided to leave the area. As a result we are
currently experiencing a shortage of highly-trained physicians,
nurses and support staff. Recruitment and retention continue to
be a major issue. We are spending over $20M annually in
employment agency fees to staff critical areas throughout our
hospitals. Wages have increased 10.65 percent as a result.
While Health System wage costs increased almost 11 percent, the
Medicare Wage Index decreased almost 4 percent. To attract the
talent we need to continue to operate, the pressure to increase
wages continues. A permanent fix to the Medicare Wage Index
would be most helpful in addressing this issue as well as
financial support to help in recruiting and retaining key
personnel especially physicians and nurses. In October 2006
Ochsner Clinic was forced to increase physician salaries by $6M
or 5 percent above pre-Katrina levels to retain and recruit
physicians to the New Orleans market. In addition, we are often
forced to pay significant recruitment bonuses to attract the
necessary staff.
Ochsner Health System also faces $4.8 million in
outstanding unemployment claims, which arose in conjunction
with Executive Orders issued by the Governor that granted
benefits to individuals unemployed as a result of the storm and
suspended many of the normal requirements for obtaining
unemployment benefits. While the Federal Government provided
$400 million in assistance to help pay for these claims, the
Louisiana Department of Labor allocated all of the Federal
relief funds to for-profit employers, leaving most non-profit
and governmental employers that are self-insured to pay an
enormous and potentially damaging amount of claims. In
response, the Louisiana State Legislature enacted legislation
that defers the payment of these claims until July 1, 2007 in
an effort to identify solutions to the problem which could
include an amendment to this Disaster Unemployment Assistance
(DUA) Fund or an appropriation to the Louisiana Unemployment
Trust Fund for the benefit of governmental and non-profit
institutions from the Federal Unemployment Trust Fund.
Funding for uncompensated care is an issue for us. Ochsner
has done more than its fair share of caring for the uninsured
in the region. We have seen 24,731 uninsured patients since
Hurricane Katrina at a cost of $25.5M and we have been
reimbursed only $12.1M; that's less than 50 cents on the dollar
for our costs. Please note that I am referring to our costs not
charges and these refer to hospital services only and do not
address our clinic load. With over one million clinic visits
per year, the effects on the Institution are simply not
understood by the traditional approaches of government at all
levels. Our uninsured and Medicaid patient volumes have
increased 50 percent from pre-Katrina levels. The time between
providing care to the uninsured and receiving reimbursement has
become excessive. We recommend that money for reimbursement for
the care of the uninsured follow the patient directly and not
go through multiple third parties to expedite funds reaching
providers on a timely basis. Predictable funding is absolutely
essential to predictable access for patients. And access is at
the core of good medical care.
As part of its ongoing contributions to the recovery of the
greater New Orleans region, Ochsner purchased three community
hospitals in Orleans and Jefferson Parishes in October 2006
from Tenet Healthcare Corporation that were temporarily closed
and significantly disabled in the aftermath of Katrina. These
hospitals, as well as Ochsner Medical Center, require extensive
disaster related infrastructure improvements at a cost of
$17.5M to retrofit and harden facilities in preparation for
future storms. These essential preparations include raising
transformers, relocating transfer switches, buying emergency
generators, drilling additional wells and replacing flooded
equipment.
We experienced significant additional costs and lost
revenues. Extraordinary costs are included in all emergency
situations as adjustments are made for the circumstances that
develop. Volumes and related revenue are down but expenses are
up significantly. There is precedent for the Federal Government
to help in similar disasters. After the September 11, 2001
attacks on New York and Washington, aid was provided to
hospitals for similar reasons. We ask for the same
consideration today. We stepped up without reservation--we bet
the company and ask for your help today.
Finally, more flexibility in the Health Resources and
Services Administration grant process would be helpful in
addressing some of the issues I have just described to you.
Anything you can do to streamline the process as well as
providing significant funds to address the shortfalls we have
experienced would be most helpful.
We need your help if we are to survive long term as the
largest healthcare provider in the State of Louisiana and to
give us the ability to respond to future disasters
successfully.
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Testimony of Kevin U. Stephens, Sr., M.D., J.D.
I am Dr. Kevin U. Stephens, Director of the City of New
Orleans Health Department. To Chairman Bart Stupak, Ranking
Member Ed Whitfield, and distinguished members and guests of
the Subcommittee on Oversight and Investigations of the U.S.
House of Representatives' Committee on Energy and Commerce:
Thank you for inviting me here today to speak on the state of
healthcare in New Orleans. Mayor C. Ray Nagin and his
administration welcome dialogue and are hopeful that this
hearing will spur positive change as we work to not only
rebuild our city's infrastructure and neighborhoods, but also
to develop a state-of-the-art, modern healthcare system.
I would like to acknowledge and thank Secretary Michael
Leavitt, represented on the panel by Leslie Norwalk, for all
the support the Department of Health and Human Services has
given to the City of New Orleans Health Department. Secretary
Leavitt and I first met on August 24, 2005, less than one week
before Hurricane Katrina, when we both visited the Ponchratrain
Senior Center and talked with community leaders and senior
citizens about Medicare. We developed a professional
relationship which has continued in the aftermath of Hurricane
Katrina. Additionally, I would like to thank Dr. Fred Cerise,
Director of the Louisiana Department of Health and Hospitals,
for his support to our city. Finally, I would like to
acknowledge Dr. Robert Lynch of South Central Veterans Affairs
Health Care. New Orleans has had a long relationship with the
local Veteran's Affairs hospital, and we look forward to
strengthening our partnership with it.
Our Health Challenges
Louisiana has historically ranked among the country's
lowest in health outcomes. For more than 10 years, Louisiana
has been either 49th or 50th in state health rankings according
to the United Health Foundation's America's Health: State
Health Rankings.The report uses nine risk factors to support
the rankings, such as the percentage of smokers in the State,
and eight health outcomes, such as cancer deaths per 100,000
residents. In addition to the high risk factors in the state,
citizens without the means to purchase private health care have
suffered from a lack of medical resources and facilities,
contributing to significant health problems. This highlights
the necessity for a stronger, proactive local healthcare
delivery system.
Charity Hospital has long been the primary source of
healthcare for the indigent and uninsured in New Orleans. In
1992, Charity and University Hospitals merged to form the
Medical Center of Louisiana at New Orleans (MCLNO). The complex
developed a reputation as one of the best Level I Trauma
Centers in the country--the only one along the Gulf Coast--and
as an excellent training facility for health professionals.
Many without private health insurance relied on its clinics as
their main source for primary healthcare.
Recent severe budget cuts forced the MCLNO to close walk-in
clinic, some operating rooms and some hospital beds. These cuts
translated into decreased access to primary and preventive
healthcare services for those who had few alternatives.
The City's 13 health clinics as well as other state and
non-profit clinics also provided services to our citizens.
However they lacked the capacity to meet the community's entire
need for healthcare.
Problems Exacerbated by Hurricane Katrina
While the situation was dire, it was soon to reach crisis
level. Hurricane Katrina, which struck on August 29, 2005, was
the largest and most costly natural disaster in American
history. More than 1,400 Louisiana residents lost their lives.
Katrina also produced the first mandatory evacuation in New
Orleans history, and the largest displacement of American
citizens in U.S. history--1.3 million people. More than 200,000
New Orleanians remain displaced.
It is estimated that New Orleans sustained 57 percent of
all the damage in Louisiana. Pre-Katrina, there were 215,000
housing units, 188,251 of which were occupied. More than 70
percent of the occupied units--134,344 units--sustained
reportable damage, and 105,155 were severely damaged.
Residential damage in New Orleans was $14 billion. In addition,
every hospital and medical facility in Orleans Parish was
closed.
Since the storm and floods, only four of the eight
hospitals in the parish have reopened, all at decreased
capacity. The City's Health Department, which employed more
than 200 health professionals, lost more than 60 percent of its
staff and closed eight of its 13 clinics. Yet, as traumatic as
this devastation was, it has given us a unique opportunity to
redesign and rebuild a model healthcare delivery system that
corrects the gaps and failures of the past.
New Orleans' population, which was more than 450,000 before
Hurricane Katrina, is now estimated to be between 230,000 and
250,000 citizens. Even with the temporarily reduced population,
approximately 20 percent of our citizens, more than 38,000
people, are uninsured. The City also has a rapidly increasing
indigent worker population. Providing healthcare services to
these uninsured citizens has placed a tremendous burden on the
healthcare providers of the surrounding parishes and those in
New Orleans that have reopened since the storm.
Another challenge has been the significant decrease in the
number of healthcare providers in the parish. According to a
2006 Blue Cross/Blue Shield report, Orleans Parish had 2,038
physicians Pre-Katrina; only 510 physicians are on their
network now. This 72 percent decrease highlights the relative
loss of medical professionals in Orleans Parish.Other evidence
can be found in a study conducted by the Louisiana Department
of Health and Hospitals. Of 202 primary care physicians who
responded to the survey, only 154 were still practicing and
just 73 accepted patients dependent on Medicaid as their source
of payment. Clearly, more providers are needed in Orleans
Parish, particularly those who care for the uninsured and
underinsured.
There is a similar story as it pertains to the capacity of
Orleans Parish hospitals. According to a 2006 report from
PriceWaterhouseCooper, New Orleans had 2,258 hospital beds
before Katrina. According to a March 2007 report from the
Metropolitan Hospital Association, Orleans Parish now has 625
staffed beds, a reduction of 75 percent.
Fortunately, neighboring Jefferson Parish lost far less of
its capacity, with its number of hospital beds decreasing from
1,922 to 1,636. Jefferson Parish hospitals have been responsive
in absorbing patients from Orleans Parish. But this does not
negate the critical need for more hospital beds to open in
Orleans Parish to meet the needs of our ever-increasing
population.
It should be noted that many parts of this region which had
the greatest impact from Katrina have no access to significant
healthcare facilities. These areas include the Lower Ninth Ward
and New Orleans East in Orleans Parish, as well as Chalmette
and other parts of St. Bernard Parish.
The difficulty in obtaining services was highlighted by the
number of citizens who attended Health Recovery Week II. Along
with Operation Blessing, Remote Area Medical, the Mayo Clinic
and International Medical Alliance, the City hosted the outdoor
clinic providing medical, dental and optical services during
the last week of January. In seven days, we provided free
medical services to more than 3,800 citizens, but given the
need, we could have served far more people.We opened at 6 a.m.
daily and by 7 a.m., we were filled to capacity for the day.
Many who received health care services had serious illnesses
that were not being controlled and were life-threatening.
Post-Katrina: City of New Orleans Health Department Role
The City of New Orleans Health Department must play a
significant role in improving the health of the residents of
our City. We need to fully staff our clinics and expand their
offerings to include all preventative and primary care
services. Since health outcomes are largely controlled by
personal lifestyle choices, public health professionals must
play a critical role in educating the public about health risks
and behavior modification. These professionals also must ensure
that we conduct the ongoing research necessary to understand
our shifting healthcare climate.
Efforts to Repair and Renew the Healthcare System
Following Hurricane Katrina, the Bring New Orleans Back
Commission, a group of City leaders convened by Mayor Nagin to
design a comprehensive plan for the city's recovery, met to
debate and decide on the future of the city's delivery of
essential services to citizens. Commission members proposed
policy recommendations for the rebuilding of the city's
healthcare system. Mayor Nagin approved the following
recommendations:
Create an area-wide healthcare and human services
collaborative that would develop a system of care for all
segments of the population, provide primary care centers linked
to hospitals and shift the focus of healthcare delivery away
from institutional care toward ambulatory care and preventative
medicine;
Develop comprehensive emergency preparedness plans for
hospitals and collect the necessary resources to implement
those plans;
Maintain a university teaching facility in New Orleans;
Empower all New Orleans citizens to play an active role in
their access to healthcare services, i.e. promoting the usage
of electronic medical records.
Once the commission made its recommendation, the city's
needs became clear but we lacked the resources to implement
them. In the spring of 2006, the One New Orleans Committee
convened to discuss how we could effectively implement the
recommendations of the Bring Back New Orleans Commission. The
Healthcare subcommittee cited the need to lobby for state funds
to assist private hospitals in the care of indigent and
uninsured patients.
The subcommittee also identified the need to amend state
policy to include reimbursements for uninsured patients
permitting the healthcare dollars to follow the patient and not
the institutions.
During the summer of 2006, the state led the Louisiana
Health Redesign Collaborative (LHRDC), which was comprised of
local and state stakeholders. Its key recommendations were:
Develop a medical home model system of care
Develop a health insurance connector
Establish a Louisiana Healthcare Quality Forum
Provide premium subsidy for uninsured children
Expand coverage to pregnant women
Give choice of coverage models, including private
insurance
Provide coverage for individuals with mental
illness and addictive disorders
Mental Health
The provision of mental health services poses a particular
challenge in a region that has experienced severe loss, death
and destruction. According the 2006 Quality of Life Survey
submitted by the University of New Orleans Survey Research
Center, 20 percent or more of residents in both Orleans and
Jefferson parishes are experiencing severe levels of stress and
depression. This is not surprising given the obstacles our
residents face in reestablishing their lives in a changed
environment.
Despite this increased need, the city has fewer than 50
hospital beds for inpatient psychiatric care--about 17 percent
of pre Katrina capacity. We estimate that only 20 of the 200
psychiatrists who were working in New Orleans before the storm
have returned to continue their practices. The city has
diligently collaborated with the LSU Health and Sciences Center
Department of Psychiatry and the Metropolitan Human Services
District to identify more mental health resources. New Orleans
has an urgent need for more inpatient psychiatric beds, as well
as new community mental health centers.
Mortality Rates
As a doctor and healthcare provider, I began to note a
dramatic increase in the number of death notices in the
newspaper since Hurricane Katrina. This observation was
supported further by the deaths of two staff people in my own
department within a short time and anecdotal accounts of
families going to more funerals than ever. Due to the lack of
current state data concerning this problem, the City's Health
Department engaged in a study to count the death notices posted
in the Times-Picayune newspaper and compared it to a parallel
period before Hurricane Katrina.
In order to validate our methodology, we compared the
number of death notices printed in the newspaper in 2002 and
2003 to the published state data from death certificates. In
both cases, the difference between the two was not
statistically significant. In 2003, we averaged 924 deaths per
month according to death notices. In contrast, for the first
six months in 2006, New Orleans averaged 1,317 death notices
per month. This means that approximately 7,902 citizens expired
in the first six months of 2006, as compared to approximately
5,544 in the first 6 months in 2003.These observations, as well
as the severity of health problems treated during our Health
Recovery Week, strongly suggest that our citizens are becoming
sick and dying at a more accelerated rate than prior to
Hurricane Katrina.
We believe these findings are significant, but the city has
reached the limits of its ability to research this important
issue. It is critical that state and federal agencies
immediately study these trends as well as the causes of death.
This information can then be used to develop appropriate
interventions.We would also recommend that the federal
government establish an electronic National Death Registry
system to track mortality rates after any disaster that
involves massive evacuation and mobilization of people across
state lines. In the case of Hurricane Katrina, New Orleans
residents were required to evacuate to more than 40 states.
Clearly, the healthcare system in New Orleans is far from
normal, but we are working diligently to make improvements. The
City of New Orleans Health Department has three proposals to
comprehensively and systematically rebuild our healthcare
system.
1. All citizens should have immediate access to primary,
preventative and mental health care services. People are
suffering now and we must respond.
2. New Orleans needs more hospital beds.The shortage of
beds has reached crisis proportions, and on some days
ambulances have to wait for hours on emergency room ramps to
offload patients.
3. We must receive the resources to rebuild our city Health
Department.Our Health Department is a necessary partner in the
repair and reconstruction of the City's healthcare system.
Our healthcare system had serious inadequacies and gaps
before Hurricane Katrina, but the storm ruptured it to a point
that many more of our citizens are have lost access to
healthcare services. Thank you for your attention to New
Orleans. We look forward to working with you to solve these
problems.
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Testimony of Donald R. Smithburg
Chairman Stupak, Ranking Member Whitfield, members of the
subcommittee, I represent the LSU Health Care Services
Division, which comprises most of the state public hospitals
and clinics that have traditionally served as the public-
teaching system in Louisiana. I must begin by expressing my
sincere gratitude for the time and attention that you and your
colleagues have devoted to understanding our plight in New
Orleans and extending your support and assistance. Many members
of this subcommittee, as well as a delegation led by Rep.
Clyburn, took time out of their hectic schedules to travel to
New Orleans to survey the suffering and devastation. These were
fact-finding missions. They also were gestures of goodwill. But
to those of us on the front lines of providing health care to
the city's residents, these visits were much more. They
reassured us that we will not have to go it alone and
reinforced Congress' commitment to helping us stabilize and
strengthen the health care delivery system. Today's hearing is
one manifestation of that commitment. We are grateful for this
opportunity and pledge to partner with you and with others
testifying today to meet our obligations.
My testimony will briefly outline steps we have taken since
Katrina to stand up some semblance of a health care delivery
system. I then will add to the chorus of voices describing the
current status of health care in New Orleans. In most respects,
words are insufficient, but I will attempt to provide some
clarity by concentrating on five key issues. I will offer
suggestions for addressing the challenges we face in the short
term. Some solutions require Federal action. Others simply
require dialogue and partnership at the state and local levels.
With oversight, guidance, and support from Congress, steps we
take in the short term can provide a solid foundation for
successful efforts well into the future.
Interim Steps
Immediately after Katrina, LSU Health Care Services
Division established limited clinic and urgent care services in
tent hospitals created in partnership with the U.S. military
and the U.S. Public Health Service. We operated a ``Spirit of
Charity'' clinic in the vacated Lord and Taylor department
store next to the SuperDome. In November 2006, we reopened part
of University Hospital as the ``LSU Interim Hospital.'' FEMA
provided $64 million in Federal funds for this renovation
provided the facility would be operated on a temporary basis.
The Interim Hospital offers all of the services that were
available at Charity and University Hospitals before the storm,
with the exception of psychiatry and inpatient rehabilitation.
It has approximately 180 beds today `` about 31 percent of its
pre-storm capacity.
The Interim Hospital now operates 20 clinics in three
buildings, which is in stark contrast to the 160 clinics that
existed before Katrina. LSU plans to open seven neighborhood
clinics in the New Orleans area as soon as zoning variances are
in place and the necessary permits are finally granted by the
city.
With the destruction and closure of Charity, the region
lost its only level I trauma center. For months, trauma
patients had to be transported hundreds of miles away to
Shreveport and Houston. LSU leased space at the suburban
Elmwood facility and began providing trauma services there in
April 2006. Those services were moved to the Interim Hospital
in February 2007.
LSU has entered into a collaboration with the Department of
Veterans Affairs for construction of joint facility to replace
the neighboring LSU and VA hospitals that were destroyed. While
this innovative and cost-saving project will not be realized
for as long as five years, the partnership and the promise of a
new, state-of-the-art academic health center does have a
positive impact on helping us resolve some of our short-term
challenges, such as attracting and retaining faculty and
researchers.
Five Key Areas of Concern
1. Medical education. Pre-Katrina statistics indicate that
nearly 70 percent of practicing medical professionals in
Louisiana completed all or part of their residency requirements
at LSU and Tulane University. Prior to Katrina, the Medical
Center of Louisiana at New Orleans (MCLNO) housed the anchor
inpatient facilities for graduate medical education in
Louisiana, hosting residency programs for both LSU and Tulane.
LSU has temporarily repositioned its residency programs in
other facilities throughout the state; however, this situation
is inconsistent with the standards of ACGME and unattractive to
academically superior medical students seeking residency slots
in top-quality teaching hospitals. Thus, it is, at best, a
temporary solution and is not sustainable in the long term.
Many of our training programs already are in jeopardy. LSU
lost its radiology program, and this impacts other programs
that require direct interaction with radiology for purposes of
proper diagnosis and treatment. We are operating with a
drastically reduced number of orthopedic surgeons. We have no
trainees in oncology or rheumatology. LSU's urology and ENT
programs are still relocated out of town. General surgeons are
under increased strain because of the manpower shortages and
the enormous trauma demands. Because the entities that accredit
residency programs have certain volume and case complexity
requirements which cannot be achieved when residents are
dispersed among a multitude of smaller, private institutions,
nearly all programs are in some degree of trouble.
Possible solutions to this crisis include:
Commitment to a new academic health center which
will restore a core facility requirement for both LSU and
Tulane medical training programs;
Authority to hire and obtain reimbursement for
private physicians to alleviate the shortage of in-house
academic medical faculty;
Funding for recruitment and retention of students,
residents, and faculty;
A summit of all stakeholders in the medical
education field in order to devise longer-term solutions.
2. Reimbursement
LSU safety net hospitals rely heavily on the Medicaid
Disproportionate Share program. This source of revenues is
critical to the system, but at the same time, CMS limitations
on the use of funds for physician services and state-imposed
disparities in the payment methodology for public and private
providers diminishes our ability to fulfill our mission to
provide care to the uninsured.
Unallowable Costs. CMS considers costs associated with
payment of physicians and CRNAs to be ``unallowable'' under
DSH. They are not regarded as ``hospital'' costs, and yet, like
safety net systems across the nation, physician services in
clinics are a critical component of service to the uninsured.
This CMS policy is especially deleterious to the capacity to
expand primary care and ultimately is more costly in terms of
resulting inpatient utilization.
As a safety net system, especially one heavily involved in
graduate medical education, LSU must support a massive base of
physicians to provide care in the hospitals and clinics. The
unreimburseable status of these major costs represents an
exceedingly significant issue for any safety net health care
system. For the LSU system of hospitals, which depends on the
uncompensated care program for the uninsured or on direct state
funding for nearly 60 percent of its revenues, the lack of a
funding stream for physicians and CRNAs has created a gaping
hole that must be filled by diverting revenues from
reinvestment in infrastructure or by tapping short-term or one-
time internal funding sources. The necessity of employing such
strategies has done significant long-term damage to our
facilities and has diminished their capacity to perform their
health care and medical education missions.
Disparity of Payment Methodologies. The Legislature limits
the authorized Medicaid revenues of the LSU hospitals but does
not limit the Medicaid revenues of any other individual public
or private facilities.
State funds appropriated in the DHH Budget for state match
for Medicaid hospital services are divided between the
categories of ``public'' (10 state public hospitals) and
``private'' (approximately 120 nonstate hospitals).\1\
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1 For fiscal year 2005 the appropriated amounts of state funds for
public and private hospital categories for services to Medicaid
recipients were approximately $192.9 million and $1.02 billion
respectively.
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Since the LSU hospitals are the only acute care facilities
in the ``public'' group, they are effectively ``capped'' with
respect to the amount of Medicaid revenues they can earn, and
hence the amount of costs they can incur in delivering services
to Medicaid patients.\2\
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2 While the appropriation bill does not identify the maximum
Medicaid revenues for individual LSU facilities, that detail is
specified in effectively binding documentation associated with it and
communicated by DHH, which manages the Medicaid budget.
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At the same time, individual community hospitals are not
limited with respect to payments for any services they provide
to Medicaid patients. While there is a fixed amount of state
funding in the Department of Health and Hospitals budget for
Medicaid match for the broad category of ``private'' hospitals,
no maximum dollar amount of Medicaid revenues is communicated
to nonstate facilities as it is to the LSU hospitals.
These differences have significant consequences as they
play out in the operation of state and nonstate hospitals:
State Public Hospitals. The LSU hospitals in recent years
have experienced a demand for services by Medicaid eligible
patients at a level that has exceeded their appropriated
Medicaid revenue limits. In this situation, if a hospital were
to serve all the Medicaid patients projected to utilize it, the
facility would incur costs that Medicaid would not reimburse
once the cap were reached. Unlike community hospitals, the LSU
hospitals do not have a sufficient base of patients with third
party payers to whom they can shift unreimbursed costs, even if
desired, and strategies are required to avoid incurring these
costs at all.
Specifically, with an appropriated Medicaid revenue limit
below the level of actual demand, administrators have faced the
necessity of implementing early-in-the-year steps to reduce
services to Medicaid eligibles. \3\
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3 In practice in some years, budget adjustments have been made
through the year-end BA-7 process to increase Medicaid spending
authority when the hospitals were generating Medicaid volume above the
appropriated level. If this course of action were routinely followed,
it would solve the problems described above, but it would also
demonstrate that the cap was unnecessary in the first place. A BA-7 is
optional, however. It cannot be presumed that matching funds will be
available or that the legislature will agree to a budget change, and
the hospitals must proceed to implement service reductions when faced
with a projected Medicaid revenue shortfall.
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Control of the volume of Medicaid services, however,
requires control of the volume of all services. Since it is not
possible to target Medicaid patients only, such general steps
as closing beds and curtailing clinic and Emergency Department
hours are required. These actions do reduce Medicaid volume,
but they also reduce the number of patients in all other payer
categories as well. The result is (1) loss of revenues from
other sources, (2) reduction of care to the uninsured, and (3)
the reduction of service volumes upon which training programs
depend. \4\
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4 The reduction in care available to the uninsured occurs as both a
direct and indirect result of curtailing Medicaid revenues and
services. The direct effect is through the general reductions in
service to all patients, as indicated. In addition, however, an
indirect effect on the uninsured results from the lost opportunity to
spread overhead costs more broadly over a larger group of Medicaid
patients. When such a payer class as Medicaid (and also Medicare and
private insurance) is enlarged, there is less overhead that must be
covered by the UCC payments for the uninsured. Consequently, a larger
share of the total cost of services to these uninsured patients
consists of payments for direct patient services. The implication of
this is that to the extent that the state public hospitals can increase
its mix of patients with third party payers, it can deliver more care
to the uninsured with no additional cost to the state.
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Nonstate Hospitals. Since the total appropriation to
private facilities does not function as a cap on individual
facilities, community hospital administrators are not faced
with the same service adjustment decisions required of their
LSU counterparts. Community hospital administrators can and do
treat Medicaid as a payer source like private insurance that
can be depended upon to pay the agreed upon rate for whatever
volume of patients is encountered. \5\
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5 If the State were to face a mid-year budget problem necessitating
cuts in Medicaid payments to private hospitals, it is possible to
adjust the rates paid for services.
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The practice of legislating separate limits on Medicaid
payments to public and private hospitals--and especially
requiring only the state hospitals to remain below an arbitrary
cap--serves no good purpose for the State. It adds no assurance
beyond the total appropriation of state funds for match to DHH
that Medicaid program expenditures will be constrained within
the appropriated level. In fact, since Medicaid is an
entitlement program and a recipient unable to access the state
public hospitals is free to utilize other providers, the public
cap could increase per recipient costs as those with a Medicaid
entitlement are driven away from the LSU hospitals and into
higher cost systems for services.
Another Medicaid financing issue that could adversely
impact our ability to fulfill our safety net mission is CMS'
proposed Medicaid cost limit regulation. On January 18, 2007,
CMS issued a proposed rule that would: 1) cap Medicaid
reimbursement to public providers at the provider's cost of
delivering Medicaid-covered services to eligible recipients; 2)
greatly restrict the sources of state match funding through
intergovernmental transfers (IGTs) and certified public
expenditures (CPEs) obtain through public providers; and 3)
require public providers to receive and retain the full amount
of Medicaid payments earned. The rule adopts a more restrictive
definition of ``public provider'' than what exists in current
law. While the Administration contends that the rule would cut
$3.87 billion from the Medicaid program over five years, survey
information from public hospitals across the country indicates
that the initial impact will be far greater.
The fact that many nonstate hospitals that currently make
IGTs would no longer be permitted to do so under the rule will
leave a gaping hole in the State's Medicaid budget. This will
lead to lower reimbursements and reductions in services.
As important as what the proposed rule specifies is what it
leaves open-ended. The rule does not define ``costs.'' There is
a real threat that graduate medical education costs will not be
included or allowed. This could mean a loss of more than $50
million per year to LSU alone.
Possible solutions to these reimbursement problems include:
Require CMS to allow public hospitals to claim
physician and CRNA costs as allowable costs under DSH;
Ask the administration to withdraw the proposed
Medicaid regulation;
Organize a ``summit'' on hospital reimbursement in
Louisiana to develop equitable and realistic solutions that
ensure proper reimbursement to all providers without
destabilizing the safety net.
3. Mental health
There has been a significant loss of capacity in the mental
health system as a result of Katrina. It is a system that
already was under stress before the storm, and inpatients from
the region, especially those without funding, were being
transferred across the state to any available facility.
Post-Katrina, the city lost over 400 mental health beds--
100 at our Charity Hospital facility and only about 40 of these
have been restored in New Orleans. The Crisis Intervention unit
at that public hospital was closed, along with all the services
of the entire safety net facility.
The crisis we continue to face is manifested in multiple
ways. At the clinical level, there is an exponential increase
in mental illness. Emergency Departments have been impacted and
are under strain because of the volume of patients whose
symptoms require special handling, facilities, and expertise
not currently available. A practice of rotation of behavioral
health patients among EDs in both Orleans and Jefferson
parishes has been implemented, and these patients and the type
of care they require have contributed to ED overcrowding in the
area. Emergency Departments were not designed to accommodate
the special needs of these patients, and certainly not in the
volume now experienced. According to one press report, police,
who reportedly answer an average of 185 mental health calls
each month, often are unable to find a hospital able and
willing to accept mentally distressed citizens. They can and do
book many of these mentally ill people into jail, but that does
not guarantee proper treatment. One prison spokesperson
reported that the jail spends $10,000 to $12,000 per month--21
percent of its total pharmaceutical budget--on psychiatric
medicine. However, the jail has only one full-time, board-
certified psychiatrist and two part-time psychiatrists to treat
2,000 inmates. It is no place to treat the seriously and
persistently mentally ill. Just this past Thursday, a mentally
ill patient who was roaming the New Orleans streets at night
with a rusty BB gun was shot by a patrolling National
Guardsman.
Potential solutions to the mental health crisis
include:Funding to open additional inpatient mental health
beds. LSU is working to establish 30-40 behavioral beds at a
vacated hospital on a lease basis. Renovation of the space will
be necessary, as will support from FEMA. But more capacity is
needed in the region.Funding for long-term care beds. More
efficient use of short-term inpatient beds requires the ability
to transfer appropriate patients to a long-term setting.
Funding for outpatient facilities. Improving the
availability of outpatient services will provide alternatives
to inpatient and ED admissions and overall reduce the stress on
hospitals. Funding for telepsychiatry. This technology would
enable the state to extend the reach of limited psychiatric
resources.Incentives and funding for recruitment and retention
of mental health professionals. The cadre of mental health
professionals was decimated by Katrina. Proper staffing is
essential to restoring both inpatient and outpatient clinical
capacity.
4. Primary care delivery system. Emergency Department
overcrowding existed prior to Katrina, but it has been severely
exacerbated post-Katrina, particularly in light of reduced
primary care capacity. Many patients present to the ED for
minor ailments that are more appropriately addressed in an
outpatient primary care setting. This reliance on the ED
stresses limited resources, is inefficient and costly, and does
not provide the patient with a coordinated, holistic approach
to care. A recent article in The Times-Picayune reported on the
crisis in New Orleans EDs. Hospitals in Orleans and Jefferson
parishes have run out of space in their emergency rooms and are
lacking sufficient numbers of acute care beds. ``There is not a
bed available anywhere in the city,'' said Jack Finn, president
of the Metropolitan Hospital Council. The waiting time in EDs
is now seven to eight hours-- approximately the time required
to drive to Dallas or Atlanta. Patients remain inside
ambulances or wait in hallways on gurneys until they can be
seen. Physicians believe that lack of swift access to primary
care is part of the problem.
Insufficient primary care capacity causes other patients to
delay seeking care until their condition worsens and becomes
severe and very expensive to treat. The likelihood of a poor
outcome only increases.
LSU is committed to a model of health care delivery that
emphasizes primary care clinics located closer to where
patients live. Primary care clinics are well-positioned to
encourage better patient access, facilitate care coordination,
and provide patient education. In a multi-specialty clinic
environment with a vigorous disease management program, it is
much easier to consider and treat the patient in a holistic
context. The popularity of the ``Medical Home'' concept for
health care reform is based on an understanding of these
principles. As envisioned by the Louisiana Health Care Redesign
Collaborative, the Medical Home Model calls for improved
communication, information exchange, and care coordination
(guided by evidence-based protocols). Such a model holds
significant promise for improving care, increasing patient
satisfaction, and controlling costs.
LSU strongly endorses the Medical Home concept. LSU's
chronic care and disease management initiatives are consistent
with the model and have produced demonstrable results in
reducing the incidence of care in expensive settings and
improving quality. We must now expand and strengthen the
network of community health centers and neighborhood clinics in
New Orleans in order to build upon these successes and optimize
the benefits of the Medical Home model of care.
LSU already has offered to devote resources to community
clinics, including a mobile ophthalmology unit made possible by
a $300,000 donation from Pfizer and New York Hospital
Association. AstraZeneca donated $1 million for a telemedicine
project to be located in clinics that will facilitate diagnosis
and specialty consultations. CLIQ is a data repository that
allows sharing of laboratory and radiology information and is
in operation at MCLNO and in PATH clinics. We have offered to
implement a clinic referral system that will assign patients
presenting at our hospitals to a community clinic for primary
care services and follow-up based on the patient's zip code.
All of these efforts demonstrate our resolve to bolster primary
care clinics and better integrate them into the state's health
care delivery system. Contrary to some fears that may exist, we
have absolutely no interest in driving community health centers
and clinics out of business. There is no upside to such a
shallow strategy. We firmly believe that our success in
delivering quality health care is dependent upon a strong and
vibrant network of community clinics. We pledge to do all we
can to support primary care clinics in the state and continue a
productive collaboration with the coalition in greater New
Orleans that is evolving.
Obviously, the availability of additional funding is
central to our ability to increase primary care capacity
through community clinics and implement the Medical Home
approach. Funding should be directed in the following areas:
Physician and other related medical services. As described
in detail below, the Centers for Medicare and Medicaid Services
(CMS) does not allow us to claim physician, certified
registered nurse anesthetist, and other ``non-hospital'' costs
under DSH. Rendering these very real and critical costs
``unallowable'' suppresses the ability of the safety net to
provide the extent of timely clinic and other physician
services that a Medical Home model requires. It is not possible
to both implement a Medical Home structure and go unpaid for
some of the most basic services that patients require. If CMS
is not willing to change its policy, additional funding is
needed to compensate for these services.
Infrastructure. A significant expansion of the network of
community health centers and clinics requires an infusion of
funds to acquire the necessary zoning changes and permits,
build new facilities, lease space where appropriate, and
provide increased staffing levels.
Information technology. The Medical Home model requires
the ability to share patient medical information throughout the
health care network. Thus, funding to develop electronic
medical records and ensure interoperability is essential.
5. Workforce
There has been an exodus of physicians and other medical
personnel from New Orleans post-Katrina. Physician specialists
are in short supply, particularly orthopedists, neurosurgeons,
ENTs, interventional and other radiologists, anesthesiologists,
and ophthalmologists. We also are experiencing a shortage of
registered nurses and medical laboratory technicians. According
to Louisiana Department of Health and Hospitals officials,
there are currently about 450 primary care physicians in the
New Orleans area, down from about 1,500 prior to Katrina. There
simply are not enough mental health professionals to meet the
growing need. The nursing shortage is so severe that annual
wage and benefit costs have topped $120,000 in some cases. We
also have had difficulty filling administrative/managerial
slots, as well as openings for maintenance workers,
electricians, and carpenters.
The reasons for the workforce shortage include hospital
closures, the slow and uncertain recovery of the region, lack
of affordable housing, and deficiencies in basic public
services, such as schools and police protection. With the
closure of Charity Hospital, medical faculty are being lured to
academic health centers in other states, and this has had a
serious adverse impact on our ability to attract and retain
medical students and residents and maintain robust medical
education programs.
Possible solutions include:
State and Federal funding that will enable
hospitals to offer financial incentives to meet workforce
needs;
Federal housing assistance; and
Commitment to a new LSU academic health center.
While this facility will not be built immediately, the
political wrangling and attempts by some to halt the process
are exacerbating an already uncertain environment that
threatens to choke off supply of future medical professionals
in the state. Widespread community support for a new facility
will allay concerns and help all hospitals recruit physicians,
nurses, and other medical staff.
Conclusion
As you know, our challenges are great. But they are not
insurmountable as long as political infighting and self-
interest are set aside in favor of the interests of patients. I
think we all agree on the problems. Our task is to marshal the
intellectual capital of the entire health care community in New
Orleans to arrive at sensible solutions that transcend
parochial interests. If we do that, we will be well on our way
to recovery. However, we cannot accomplish our mission without
additional Federal assistance in the form of increased funding
and regulatory changes as outlined above. It is my hope that
the interest, attention, and influence of this subcommittee can
help facilitate a productive dialogue and produce positive
change for the citizens of New Orleans.
Answer to Submitted Question from Mrs. Blackburn
1. Regarding the mental health crisis in New Orleans, you
recommend a variety of funding options, such as funding for
outpatient facilities and long-term care beds, to alleviate the
crisis.
Who should pay for these additional beds and services?
Federal and/or State government?
With the ``brain drain'' occurring in New Orleans, who will
care for these patients once you have more beds?
Prior to Katrina, the Medical Center of Louisiana at New
Orleans (MCLNO) operated 100 acute psychiatric beds on the
Charity Hospital Campus. Charity is closed, and there currently
are no psychiatric beds in the LSU interim facility, which is
partially open with 179 acute beds. There were just over 500
total beds at MCLNO prior to Katrina.
As indicated in testimony, LSU is working to open about 40
psychiatric beds in a vacated hospital on a leased basis. As
temporary replacement beds, FEMA funding for necessary
renovation will be requested.
Plans for the construction of a replacement hospital for
MCLNO in conjunction with the Veterans Administration should
address the need for acute psychiatric beds on a permanent
basis. The Community Development Block Grant will partially
fund the hospital, with the remainder provided by bonds and
FEMA replacement funds. Ongoing operation of the psychiatric
beds in a new hospital is anticipated to be supported by state
and Federal Medicaid funding, by Medicare and by various
private insurance sources.
Recruitment of psychiatrists and other professional staff
is problematic today and will require both continued state and
Federal efforts to encourage successful recruitment of health
care professionals to the area and the rebuilding of New
Orleans generally. Financial incentives, such as through the
Greater New Orleans Health Service Corp which offers grants to
physicians who return and practice for at least three years,
will be critical to success.
Availability of psychiatrists and other specialists is a
complicating issue over and above facility needs. It is
impossible to determine the pace at which the ``brain drain''
problem in New Orleans will be resolved, but a solution must go
hand-in-hand with other efforts to restore our health care
system and community in general.
MCLNO is attempting to open seven primary care clinics in
various areas of metro New Orleans. While we continue to await
city enactment of its zoning variance ordinance, it is
estimated that these clinics will support 52,000 to 70,000
patient visits annually. While the clinics will not be
providing specialty psychiatric services, they clinics will be
able to screen for such problems and direct care to settings
other than the Emergency Room. Such enhancement of the primary
care delivery system will be important in unclogging Emergency
Rooms and making them more accessible for emergent problems of
all types. It is important to maintain focus on repairing the
health care system as a whole in order for it to effectively
address various kinds of specialized care.
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Diane Rowland Answers to Submitted Questions from Mr. Green
Your testimony referred to the Disaster Relief Medicaid
Program for New York after the tragedy of September 11, 2001,
and how a different approach--the waiver process--was utilized
to address Medicaid issues as a result of Hurricane Katrina.
There is no question that the Federal response was more
effective in New York, so I would like to explore why CMS did
not build on that experience to respond more effectively to
Katrina.
In your opinion, what factors contributed to the use of a
waiver approach, and did you sense a lack of political will to
respond in a manner similar to the response after the attacks
of September 11, 2001?
Additionally, what legislative changes would you suggest we
make to ensure that the Medicaid program can effectively
respond to a disaster and provide real help to Americans during
a public health emergency?
On September 19, 2001, 8 days after the terrorist attacks,
New York Governor George Pataki announced a program called
Disaster Relief Medicaid. The state had received Federal
approval to implement a program to address the challenges
Medicaid administrators faced as they attempted to operate with
computer systems rendered defunct in the wake of the attacks.
The program also addressed the health needs of New York
residents by providing temporary Medicaid coverage beyond the
scope of coverage available prior to September 11th. In the
four months between the terrorist attacks and the end of
January 2002, when New York's Disaster Relief Medicaid closed
to new enrollees, over 350,000 New Yorkers signed up for the
program. \1\
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1 K. Haslanger, ``Radical Simplification: Disaster Relief Medicaid
in New York City,'' Health Affairs 22(1):252-8, January-February 2003.
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Included in New York's Disaster Relief Medicaid were
administrative simplifications that made it easier for New
Yorkers to apply for coverage and expanded eligibility levels
for Medicaid, particularly for adults. The state shifted from
an eight-page Medicaid application to a single page and
dramatically reduced the amount of documentation applicants
were required to present. Eligibility interviews lasted about
fifteen minutes and determinations were made on the spot,
reflecting a change in procedure that appealed to low-income
residents who could leave the interview with an assurance of
immediate coverage.\2\
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2 M. Perry, ``New York's Disaster Relief Medicaid: Insights and
Implications for Covering Low-Income People,'' Kaiser Commission on
Medicaid and the Uninsured and the United Hospital Fund, pub No. 4062,
August 2002.
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The state also increased eligibility levels for adults in
New York City that had been approved but not put into operation
as part of the state's Family Health Plus waiver in 1999, and
it administratively implemented a New York Court of Appeals
decision that required Medicaid to enroll all legal immigrants
in the state, regardless of whether they arrived before or
after 1996.
The State and Federal Government quickly partnered to
implement New York's Disaster Relief Medicaid, putting in place
within weeks a solution for those still grappling with the
health and emotional aftershocks of the terrorist attacks.
Simplified documentation requirements and application materials
as well as expanded eligibility enabled more individuals to
apply for and enroll in public coverage. An extensive outreach
campaign, aided by private philanthropy and fed by the positive
experiences applicants had with New York's Disaster Relief
Medicaid, helped link vulnerable residents with health coverage
and services.
In their September 2006 article in the Journal of the
American Medical Association, Jeanne Lambrew and Donna Shalala
reflect upon the Federal health policy response to Hurricane
Katrina and provide suggestions to improve the Federal response
to future disasters.\3\
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3 J. Lambrew and D. Shalala, ``Federal Health Policy Response to
Hurricane Katrina: What It Was and What It Could Have Been,'' JAMA
2006;296:1394-7.
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To mitigate against future harmful delays in the Federal
health response to disasters, Lambrew and Shalala recommend
that Congress consider enacting a permanent emergency Medicaid
authority that could build upon the program's existing
eligibility and payment systems to address health coverage
needs after disasters. Fully-funded, temporary expansions to
broad or targeted groups could be triggered by legislative
criteria or an executive agency designation. Lambrew and
Shalala also point out that Congress and the executive branch
can employ budget policy to appropriate funds for public health
programs, such as through the Public Health and Social Services
Emergency Fund. A reserve for use in disasters could be
retained in this fund, which would revert to the Treasury if
unspent.
In the face of the massive destruction to the Gulf Coast,
and especially the New Orleans region, in the aftermath of
Katrina there was no ready mechanism to extend coverage to the
displaced, uninsured population and assist the providers trying
to meet their health needs. Having emergency authority to
extend Medicaid coverage and provide full Federal financing in
disasters from a disaster reserve fund would provide an
important safety net for the needy in times of crisis.
The witnesses on the hearing's second panel shared
different views about the effect of CMS' proposed rule on
Medicaid financing and limitations to cost. Given that the
public hospital infrastructure has been crippled due to
Hurricane Katrina and the private hospitals have taken on the
bulk of uncompensated care, can you address the likely effect
of this proposed rule on New Orleans' ability to shoulder
uncompensated care costs?
This question seems to arise from Gary Muller's testimony
stating: ``as we understand the proposed rule, CMS will require
states to direct Federal funds back to governmentally operated
healthcare providers. This certainly seems to be aligned with
how the Federal Government intended these funds to be used in
the first place. For WJMC, we believe this will result in
equitable distribution of funds to our hospital.''
It seems that there is a misunderstanding about how the
regulation would affect hospitals and providers and some
confusion with this regulation and the way the state currently
distributes Medicaid disproportionate share hospital payments
(DSH). DSH is the primary mechanism used to support
uncompensated care in Louisiana and the majority of Medicaid
DSH funds are now targeted to the Charity Hospitals. This rule
does not impact or affect the distribution of DSH payments.
The proposed rule would place new restrictions on
reimbursement for government providers and limit the definition
of a public hospital which restricts a states' ability to use
intergovernmental transfers and certified public expenditures
to fund their programs. The American Hospital Association, the
National Association of Public Hospitals and the American
Health Lawyers Association have all submitted comments to CMS
to request that the rule not be implemented or significantly
changed because of the impact of the regulations on safety-net
providers and on how states fund their Medicaid programs.
Ultimately, these changes could leave states with less funding
available for safety-net providers which could further hinder
efforts to support uncompensated care. Because Louisiana has in
the past relied on intergovernmental financing arrangements to
fund the charity system more heavily than other states, the
proposed rule could have a larger impact on safety-net
financing in Louisiana compared to other states. If the rule is
implemented, it could also limit the state's ability to use
similar financing arrangement with other public providers in
considering options to restructure the health care delivery
system.
For more specific comments about the regulation see the
following:
http://www.aha.org/aha/letter/2007/070315-cl-cms2258p.pdf
http://www.naph.org/naph/advocacy/NAPHCommentLetter.pdf
http://www.gwumc.edu/sphhs/healthpolicy/chsrp/downloads/
AHLA--medicaid--IGT--030907.pdf
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Gary Wiltz, M.D. Answers to Submitted Questions
Question Submitted by Hon. Gene Green
I am a strong proponent of health centers and understand
the tremendous job the do to serve the uninsured. The cities of
Houston and New Orleans both have high levels of uninsured with
too few FQHCs to meet the need. So, I appreciate the challenges
you face.
I understand that you have worked with Governor Blanco to
craft a proposal for health center construction. Can you
provide the committee with additional details on that proposal
and explain how it will be utilized to leverage additional
health care financing?
Additionally, with health centers saving three Medicaid
dollars for every one federal dollar spent on them, there is no
question that FQHCs are a good use of scarce health care
dollars. As we look at rebuilding health care in New Orleans,
can you on what role FQHCs will--or should--play in the
reconstruction of the health care system?
For the first time in Louisiana Federally Qualified Health
Center's (FQHC) history, a one time special capital outlay set
aside has been allocated with the Governor's budget to expand
existing site and service expansion initiatives. Louisiana
Primary Care Association (LPCA) is currently working with
Capital Link, Inc. to develop a capital funding program for
FQHCs that would leverage New Market Tax Credits (NMTC) funding
and HRSA or USDA Loan Guarantee Programs to maximize funding
available for FQHC infrastructure development. The program
under consideration would require a state investment of $55
million in CDBG or other state funds to leverage approximately
$38 million in NMTC, private sector investments and $33 million
in HRSA or USDA guaranteed low-cost loans. This pool of $126
million would fund the expansion and new site development of 58
health centers and the acquisition of 11 electronic medical
record (EMR) systems. The health center expansion and new
access point initiative is projected to provide health care to
an additional 180,000 Louisianans.
Subsequent to the tragedies of Hurricanes Katrina and Rita,
health officials within the state have deemed FQHCs as a viable
option for public and private partnering as Louisiana
reengineer its fragile health care infrastructure. Louisiana
currently ranks 50th in the nation in poor health indicators,
and the cost of health care is spiraling upward due to
unwarranted emergency room visits to Louisiana's charity
hospitals. The average cost per ER visit is $383. Nevertheless,
the average cost to see that same patient in one of Louisiana's
Health Centers is $130. Louisiana's Governor Kathleen Blanco
has expressed on several occasions the need for a better
community based system of care. The Louisiana's Health Care
Redesign Collaborative has echoed the same sentiment proposing
the ``medical home'' concept as the model for redesigning
Louisiana's health care system. The medical home concept
includes four basic components which are similar to the
federally qualified health center's model--access to a primary
care physician (PCP), an insurance connector, a Quality Forum
and a health information technology system.
Most importantly, Louisiana's FQHCs are staffed by PCPs
and nurse practitioners. Louisiana's FQHCs provide dental and
mental health services, access to prescription assistance
programs and the 340B program which provides for lost cost and
in some cases free prescription drugs. The majority of
Louisiana's FQHCs are Certified Medicaid Application Centers
which serves as an ``insurance connector''. FQHCs are governed
by a 51 percent consumer majority board similar to that of the
Quality Forum--the establishment of a forum to oversee the
quality of the care provided by the Medical Home. Additionally,
many of Louisiana's FQHCs are JCAHO accredited or are applying
for re-accreditation.
Question Submitted by Hon. Ed Whitfield
Ms. Diane Rowland stated that pre-Katrina New Orleans had
only two federally qualified health centers (FQHCs). Can FQHCs
play a larger role in New Orleans? If so, what impediments do
you see to the expansion of FQHCs at the federal, state, and
local level?
There are two Federally Qualified Health Center
organizations in New Orleans. One is the New Orleans Health
Department Healthcare for the Homeless Program and the other is
EXCELth, Inc. which operates the EXCELth, Inc. Primary Care
Network (the EXCELth Network). The Health Care for Homeless
program takes in more than its traditional population as a
result of the effects of Katrina. As a network, the EXCELth
Network has multiple sites in Orleans, Jefferson and East Baton
Rouge Parish. Two sites are operated by the Daughters of
Charity Services of New Orleans in Orleans Parish and one more
in Jefferson. Two EXCELth Network sites are operated by the New
Orleans Health Department in Orleans Parish. There is another
EXCELth clinic in East Baton Rouge, as well as, two mobile
medical units operated by EXCELth, Inc. in New Orleans and East
Baton Rouge (that goes mainly FEMA trailer sites).
However, there are additional FQHCs in the New Orleans
Metro area. Jefferson Community Health Care Centers (JCHCC) is
an FQHC in adjoining Jefferson Parish. St. Charles Community
Health Care Center (St. Charles) operates in St. Charles Parish
and in Kenner, LA, part of Jefferson Parish.
In post-Katrina Metro New Orleans, the collaboration
between the FQHC organizations has been remarkable in that they
have worked together to expand services by sharing their
resources. The organizations regularly meet among themselves
and other safety net providers to plan services to assure that
gaps are addressed. A case in point is the March of Dimes
Mobile Pre-Natal Van (The MOM Van). Collectively the EXCELth,
JCHCC, Daughters of Charity and St. Charles Health Centers
submitted a successful proposal to the national March of Dimes
to operate the Mobile unit to outreach underserved communities
in the combined Orleans and Jefferson area. Each has taken
different roles to assure coordination and comprehensive care
of this population at particular risk due to the loss of pre-
natal providers in the area.
In this respect, the best solution for addressing the
needs of the New Orleans area is to support the existing
organizations that have bonded together and increased their
capacity to provide community solutions. Additional, support to
these organizations will increase their collective capacity and
the opportunity for success.
Impediments that affect these health centers are generally
the difficulties in quick resolution to financial and policy
needs at Federal and state levels. Most have seen increased
uncompensated costs (uninsured rates have increase to 80
percent in some sites of service). While block grants have
helped, the limited and unpredictable length of their existence
impedes practical planning of service delivery and response.
Additionally, long term support for increasing workforce
availability is also critical.