[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
POST-KATRINA RECOVERY: RESTORING HEALTH CARE IN THE NEW ORLEANS REGION
=======================================================================
HEARING
before the
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
DECEMBER 3, 2009
__________
Serial No. 111-64
__________
Printed for the use of the Committee on Oversight and Government Reform
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
index.html
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COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM
EDOLPHUS TOWNS, New York, Chairman
PAUL E. KANJORSKI, Pennsylvania DARRELL E. ISSA, California
CAROLYN B. MALONEY, New York DAN BURTON, Indiana
ELIJAH E. CUMMINGS, Maryland JOHN L. MICA, Florida
DENNIS J. KUCINICH, Ohio MARK E. SOUDER, Indiana
JOHN F. TIERNEY, Massachusetts JOHN J. DUNCAN, Jr., Tennessee
WM. LACY CLAY, Missouri MICHAEL R. TURNER, Ohio
DIANE E. WATSON, California LYNN A. WESTMORELAND, Georgia
STEPHEN F. LYNCH, Massachusetts PATRICK T. McHENRY, North Carolina
JIM COOPER, Tennessee BRIAN P. BILBRAY, California
GERALD E. CONNOLLY, Virginia JIM JORDAN, Ohio
MIKE QUIGLEY, Illinoia JEFF FLAKE, Arizona
MARCY KAPTUR, Ohio JEFF FORTENBERRY, Nebraska
ELEANOR HOLMES NORTON, District of JASON CHAFFETZ, Utah
Columbia AARON SCHOCK, Illinois
PATRICK J. KENNEDY, Rhode Island BLAINE LUETKEMEYER, Missouri
DANNY K. DAVIS, Illinois ANH ``JOSEPH'' CAO, Louisiana
CHRIS VAN HOLLEN, Maryland
HENRY CUELLAR, Texas
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
PETER WELCH, Vermont
BILL FOSTER, Illinois
JACKIE SPEIER, California
STEVE DRIEHAUS, Ohio
JUDY CHU, California
Ron Stroman, Staff Director
Michael McCarthy, Deputy Staff Director
Carla Hultberg, Chief Clerk
Larry Brady, Minority Staff Director
C O N T E N T S
----------
Page
Hearing held on December 3, 2009................................. 1
Statement of:
Brand, Marcia K., Ph.D., Deputy Administrator, Health
Resources and Services Administration, U.S. Department of
Health and Human Services; Alan Levine, secretary,
Louisiana Department of Health and Hospitals; Joia Crear-
Perry, M.D., FACOG, director of clinical services, Health
Department, city of New Orleans; and Clayton Williams, MPH,
director, Louisiana Public Health Institute................ 120
Brand, Marcia K.,........................................ 120
Crear-Perry, Joia........................................ 145
Levine, Alan............................................. 131
Williams, Clayton........................................ 159
DeSalvo, Karen B., M.D., MPH, MSC, executive director, Tulane
University Community Health Centers; Cynthia A. Bascetta,
Director, Health Care, U.S. Government Accountability
Office; Diane Rowland, executive vice president, the Henry
J. Kaiser Family Foundation; Donald T. Erwin, M.D.,
president and chief executive officer, nephrology, St.
Thomas Community Health Center; Michael G. Griffin,
president and chief executive officer, Daughters of Charity
Services of New Orleans; Alice Craft-Kerney, executive
director, Lower Ninth Ward Health Clinic; and Roxane A.
Townsend, assistant vice president, health systems,
University Hospital, Louisiana State University System..... 8
Bascetta, Cynthia A...................................... 24
Craft-Kerney, Alice...................................... 43
DeSalvo, Karen B......................................... 8
Erwin, Donald T., M.D.................................... 49
Griffin, Michael G....................................... 55
Rowland, Diane........................................... 74
Townsend, Roxane A....................................... 63
Letters, statements, etc., submitted for the record by:
Bascetta, Cynthia A., Director, Health Care, U.S. Government
Accountability Office, prepared statement of............... 26
Brand, Marcia K., Ph.D., Deputy Administrator, Health
Resources and Services Administration, U.S. Department of
Health and Human Services, prepared statement of........... 123
Craft-Kerney, Alice, executive director, Lower Ninth Ward
Health Clinic, prepared statement of....................... 45
Crear-Perry, Joia, M.D., FACOG, director of clinical
services, Health Department, city of New Orleans, prepared
statement of............................................... 148
DeSalvo, Karen B., M.D., MPH, MSC, executive director, Tulane
University Community Health Centers, prepared statement of. 12
Erwin, Donald T., M.D., president and chief executive
officer, nephrology, St. Thomas Community Health Center,
prepared statement of...................................... 51
Griffin, Michael G., president and chief executive officer,
Daughters of Charity Services of New Orleans, prepared
statement of............................................... 57
Issa, Hon. Darrell E., a Representative in Congress from the
State of California, prepared statement of................. 7
Kucinich, Hon. Dennis J., a Representative in Congress from
the State of Ohio, prepared statement of................... 107
Levine, Alan, secretary, Louisiana Department of Health and
Hospitals, prepared statement of........................... 134
Rowland, Diane, executive vice president, the Henry J. Kaiser
Family Foundation, prepared statement of................... 76
Towns, Chairman Edolphus, a Representative in Congress from
the State of New York:
Letter dated December 2, 2009............................ 118
Prepared statement of.................................... 3
Townsend, Roxane A., assistant vice president, health
systems, University Hospital, Louisiana State University
System, prepared statement of.............................. 65
Watson, Hon. Diane E., a Representative in Congress from the
State of California, prepared statement of................. 182
Williams, Clayton, MPH, director, Louisiana Public Health
Institute, prepared statement of........................... 162
POST-KATRINA RECOVERY: RESTORING HEALTH CARE IN THE NEW ORLEANS REGION
----------
THURSDAY, DECEMBER 3, 2009
House of Representatives,
Committee on Oversight and Government Reform,
Washington, DC.
The committee met, pursuant to notice, at 2 p.m., in room
2247, Rayburn House Office Building, Hon. Edolphus Towns
(chairman of the committee) presiding.
Present: Representatives Towns, Cummings, Kucinich,
Tierney, Watson, Connolly, Quigley, Kaptur, Kennedy, Lee, Issa,
Bilbray, Jordan, Flake, Chaffetz, Luetkemeyer, and Cao.
Staff present: John Arlington, chief counsel--
investigations; Jean Gosa, clerk; Adam Hodge, deputy press
secretary; Carla Hultberg, chief clerk; Chris Knauer, senior
investigator/professional staff member; Phyllis Love, Ryshelle
McCadney, and Christopher Sanders, professional staff members;
Mike McCarthy, deputy staff director; Leah Perry, senior
counsel; Ophelia Rivas, assistant clerk; Jenny Rosenberg,
director of communications; Leneal Scott, IT specialist; Ron
Stroman, staff director; Gerri Willis, special assistant;
Lawrence Brady, minority staff director; John Cuaderes,
minority deputy staff director; Rob Borden, minority general
counsel; Jennifer Safavian, minority chief counsel for
oversight and investigations; Frederick Hill, minority director
of communications; Adam Fromm, minority chief clerk and Member
liaison; Kurt Bardella, minority press secretary; Ashley
Callan, minority counsel; and Molly Boyl, minority professional
staff member.
Chairman Towns. The committee will come to order.
It has been nearly 4 years since Hurricane Katrina
devastated the New Orleans region. Since then, the area has
struggled to regain its footing and slowly rebuild its
neighborhoods, businesses, and critical services. One area
particularly hard-hit by the storm was the region's health care
infrastructure. When Katrina flooded the city and surrounding
parishes, many important hospitals and outpatient clinics were
severely damaged and destroyed.
Before the storm, the low-income population of the region
often relied on hospital emergency rooms and outpatient
clinics, mostly hospital-based, as its main source of primary
care. Charity Hospital, which was the major public hospital and
the source of many of these services, particularly for the
working poor and uninsured, was flooded and essentially
destroyed. It remains shuttered today.
Because this and other critical health care facilities were
destroyed, many of the region's residents struggled to obtain
health care after the storm. Those facilities that remain open,
particularly those willing to take the uninsured or poor, had
limited capacity and significant waiting times. While
eventually some organizations were able to open some clinics,
major health care delivery gaps remained for months and even
years after Hurricane Katrina.
In July 2007, the Department of Health and Human Services,
with money granted from Congress to restore the Gulf Coast
region, provided a $100 million grant to the State of
Louisiana. This funding, called the Primary Care Access and
Stabilization Grant, was designed to restore and expand
critical and primary care services to the region without regard
to a patient's ability to pay. The grant was also intended to
reduce costly reliance on emergency room use for primary care
services for patients who were uninsured, underinsured, or
covered by Medicaid.
The good news is that an impressive network of health
clinics has emerged which are now providing critical health
care services. As of June 22, 2009, over $80 million of the
$100 million Federal grant had been distributed and these
clinics are now collectively providing care for over 160,000
individuals in the Katrina-affected region, nearly half of whom
are uninsured. However, because the region does not have a
clear plan on when it will begin breaking ground on a
replacement for Charity Hospital, and because there are no
clear plans on how to financially sustain these clinics, part
of the region's population faces an uncertain future.
I am particularly interested in understanding what needs to
be done to ensure that we preserve the critical health services
these clinics are currently providing. In addition, it has now
been more than 4 years since Hurricane Katrina destroyed
Charity Hospital. While a temporary facility is providing
critical care to the region, we will hear today that this
interim hospital is reaching capacity. Four years is long
enough for a plan for a replacement facility to sit in limbo,
and I look forward to hearing how and when we can expect a new
hospital will be built.
Let me conclude by thanking our witnesses today,
particularly those who have traveled from the New Orleans
region to be with us today. We really appreciate your being
here. Many of you were in the trenches in the hours and days
following this storm and provided critical care to those who
otherwise would have gone without, and we thank you for that.
Your story is an important one and needs to be heard. I applaud
your efforts and I am sure all my colleagues remain committed
to helping you rebuild the New Orleans region. Today's hearing
is one more step toward that end.
I will now recognize the ranking member, Mr. Darrell Issa
of California, for his opening statement.
[The prepared statement of Chairman Edolphus Towns
follows:]
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Mr. Issa. Thank you, Mr. Chairman, and thank you for
holding this important hearing.
Although the devastation of Hurricane Katrina occurred over
4 years ago, its effects on the New Orleans region is still
being felt by its residents today. The health care
infrastructure was hit especially hard and has not fully
bounced back. The picture of health care in the New Orleans
area is still very bleak. Hospitals remain shuttered,
physicians are short in supply, and many residents, as you
said, nearly half, are uninsured.
A key number of hospitals that served the uninsured
population prior to Hurricane Katrina remain closed. As a
result of these closures, many New Orleans residents now go to
outpatient clinics for care. This change and the causes
necessary are our focus here today, and in fact, how to get to
a healthier community with a permanent hospital remains a
vexing problem that we will hear about.
Receiving early care and proper treatments will reduce
overall costs, and certainly reduce the strain on emergency
rooms. A primary care focus can reduce overall health care
spending by eliminating emergency room costs, room cost
shifting. Unfortunately, many clinics are filled to capacity in
the region. And as you said, Mr. Chairman, the economic
conditions in New Orleans continue to prevent the rebounding of
the robust economy that could in fact fund new hospital
maintenance on a permanent basis.
The Federal Government has limited resources. It is clear
that we have to work together to find a way for the region to
be self-sustaining when possible. But today we will hear that
is not possible today. Certainly we will also hear that a
leading factor in the nationwide physician shortage is the high
cost of medical liability insurance and malpractice insurance.
As a result, broader health care reform is needed here in
Congress. We need to look seriously at tort reform and bring
health care costs that make delivery systems so expensive and
inefficient down.
Additionally, as the chairman knows, public hospitals today
have certain limited immunity from tort. Bills being considered
in the Congress here today would strip that immunity, thus
raising the cost of public health and their liability
insurance.
So I hope in addition to dealing with the devastation of
Hurricane Katrina that lingers on in New Orleans, we will
recognize that there is not unlimited amounts of money to pay
for health care unless health care can be delivered in an
efficient and effective fashion. Today we will look at whether
or not we can restore New Orleans' ability to have primary
health care delivered in a way that is sustainable, cost-
effective, and will prevent the citizens from having either
poor health or excessive trips to the emergency room.
Mr. Chairman, I thank you for holding this hearing, and I
yield back.
[The prepared statement of Hon. Darrell E. Issa follows:]
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Chairman Towns. Thank you very much for your statement and
also your involvement in this issue over the years.
I would like to introduce our first panel of witnesses that
will be testifying today: Ms. Cynthia Bascetta, Director of
Health Care, U.S. Government Accountability Office; Dr. Karen
B. DeSalvo, vice dean for community affairs and health policy
and C. Thorpe Ray Chair in internal medicine at Tulane
University School of Medicine. I would also like to introduce
Ms. Alice Craft-Kerney, executive director of the Lower Ninth
Ward Health Clinic in New Orleans; Dr. Donald T. Erwin,
president and CEO of the Saint Thomas Community Health Center
in New Orleans; Dr. Michael G. Griffin, president and CEO of
Daughters of Charity Services of New Orleans; Dr. Roxane A.
Townsend, assistant vice president for health systems for
Louisiana State University; and, Dr. Diane Rowland, executive
vice president of the Henry J. Kaiser Family Foundation.
Ladies and gentlemen, it is a longstanding policy that all
of our witnesses are sworn in. So if you would stand and raise
your right hands.
[Witnesses sworn.]
Chairman Towns. Let the record reflect that all the
witnesses have answered in the affirmative.
Dr. DeSalvo, why don't we start with you. And thank you
again for coming.
STATEMENTS OF KAREN B. DeSALVO, M.D., MPH, MSC, EXECUTIVE
DIRECTOR, TULANE UNIVERSITY COMMUNITY HEALTH CENTERS; CYNTHIA
A. BASCETTA, DIRECTOR, HEALTH CARE, U.S. GOVERNMENT
ACCOUNTABILITY OFFICE; DIANE ROWLAND, EXECUTIVE VICE PRESIDENT,
THE HENRY J. KAISER FAMILY FOUNDATION; DONALD T. ERWIN, M.D.,
PRESIDENT AND CHIEF EXECUTIVE OFFICER, NEPHROLOGY, ST. THOMAS
COMMUNITY HEALTH CENTER; MICHAEL G. GRIFFIN, PRESIDENT AND
CHIEF EXECUTIVE OFFICER, DAUGHTERS OF CHARITY SERVICES OF NEW
ORLEANS; ALICE CRAFT-KERNEY, EXECUTIVE DIRECTOR, LOWER NINTH
WARD HEALTH CLINIC; AND ROXANE A. TOWNSEND, ASSISTANT VICE
PRESIDENT, HEALTH SYSTEMS, UNIVERSITY HOSPITAL, LOUISIANA STATE
UNIVERSITY SYSTEM
STATEMENT OF KAREN B. DeSALVO
Dr. DeSalvo. Good morning, Mr. Chairman and members of the
committee.
My name is Dr. Karen DeSalvo, and I am a practicing primary
care physician in New Orleans. I also serve as the director of
the Tulane University Community Health Centers.
Thank you for the opportunity to speak on behalf of my team
and our patients, and to update you on the progress of health
sector recovery in New Orleans, the challenges ahead for
sustainability of the community health network, and describe
strategies that may help us sustain these gains.
In a now too-familiar story, the failure of the Federal
levees in August 2005 resulted in the devastation of the
greater New Orleans community, including our health sector. In
the face of this crisis, the community realized we had a chance
not just to rebuild our city but to re-make it into one worthy
of our historic importance to our Nation, one that could be a
model for others. This vision extended to redesigning our
health sector into one that would provide all our citizens with
access to high quality, affordable health care.
The rationale for re-making our health sector was simple.
For decades it had performed amongst the worst in quality,
cost, and disparities. Any discussion of a redesigned New
Orleans health care sector has to include consideration of the
role of the public hospital. The Medical Center of Louisiana at
New Orleans, formerly known as Charity Hospital, served as the
principal source of care for hundreds of thousands of uninsured
and underinsured persons in the region. Yet in spite of good
intentions, at the time of the storm the system was overwhelmed
and under-funded. Primary care services offered limited hours
that reflected the schedules of medical student trainees and
other doctors rather than patients. They generally did not see
the same doctor on a concurrent visit, and if they missed an
appointment, it was a 12-month wait until the next available
one.
Most of the uninsured received their care through emergency
rooms as a result, and there was also not an alternative
network of community care to pick up the slack. When Charity
closed because of Katrina-related flooding, its patients lost
access to the chief source of care available to them. Into the
vacuum created by this closure, a grassroots, largely volunteer
effort emerged to provide care. Tulane's part in this was
initially led by a handful of our medical residents who set up
six urgent care stations on the streets of New Orleans while
the city was still under mandatory evacuation and partially
flooded.
These trainees realized that people would need care,
particularly the low-income and marginalized populations that
Tulane had cared for at Charity for the past 170 years. One of
these makeshift first aid stations evolved into a permanent
primary care site, Covenant House. When the dust had settled,
stakeholders set to work to define a vision for our rebuilt
health system. We envisioned one founded upon community health
care marked by quality and efficiency, because the evidence is
clear that this kind of framework leads to better health and it
also leads to lower costs. The public hospital needs to be a
part of this new model, but it should not be the sole source of
the primary care safety net.
In the spring of 2007, I testified, along with others,
about the challenges in health care recovery in post-Katrina
New Orleans. We were less than 2 years from the disaster at
that point, and had much work to do to rebuild. The community
was unified in asking for assistance to shore up what had
become our new paradigm of health care in our recovering city--
community health. The result of that hearing was the awarding
of the Primary Care Access and Stabilization Grant [PCASG], a
reflection of the bipartisan support for the community-based
model of care.
Tulane has used these PCASG funds to expand access to
thousands by increasing the capacity at our main site, Covenant
House. That once makeshift first-aid station has grown into a
robust, comprehensive NCQA-recognized patient-centered medical
home. Our team is proud to have built a program that offers
primary care for all ages. We have onsite integrated mental
health and resiliency programs. We offer social work and legal
aid services. We use an electronic health record. And we have
active quality improvement and evidence-based medicine
programs.
We are engaged in work force training for physicians,
nurses, social workers, public health students, and
pharmacists, all in partnership with local universities. We
also partner actively with community organizations and members
to empower them to become physically, mentally, and
economically healthier. Demand for our services has been so
high we have outgrown our space and will soon move to a new
location in the same neighborhood. Our new site will be a
renovated building that has been blighted since Katrina and
will serve as a cornerstone of economic development for that
neighborhood.
Tulane has also expanded beyond Covenant House due in large
part to PCASG funding. We provide high quality, culturally
competent care throughout the city from mobile units, school-
based health centers, and a new primary care site in
collaboration with the Mary Queen of Vietnam Development Corp.
in New Orleans East.
The people we serve are mostly the working poor. Their
employers do not offer health insurance and they are not poor
enough to be eligible for Medicaid. Others have recently lost
their insurance when they lost their jobs, like a man I saw
recently in New Orleans East. He had been laid off and was
newly uninsured. He developed a new problem that caused him to
visit the emergency room the night before he had been diagnosed
with painful gout. This was a genetic condition he suffers
through no fault of his own, and was exacerbated by his
compliance with his blood pressure medications. The emergency
room knew of our services, sent him to us and now he is
integrated into our medical home and has a medical team that
will help him manage his care, and he will not need to rely on
emergency rooms in the future.
I am quite proud of what we have accomplished as an
individual organization, but perhaps more proud of the
collective efforts. I believe our experience is a model program
for other areas. However, my enthusiasm is tempered by the
knowledge that in the fall of 2010, the funding comes to an
abrupt halt. The quality network of care for our population of
largely uninsured working poor will need to be scaled down
dramatically, perhaps as much as 40 percent, leaving some
50,000 citizens or so without access to primary community and
community health.
We will lose our gains from this investment and tens of
thousands of citizens will have to revert to the old option of
using expensive emergency rooms, which the taxpayers ultimately
bear the burden of cost. Tulane community health programs will
not be immune from these cutbacks.
To prevent the loss of gains from this investment, a set of
strategies are needed, and none alone are likely to be
sufficient. Some are within the control of the community health
providers themselves.
Chairman Towns. Dr. DeSalvo, would you wrap up, please?
Because you're beyond your 5 minutes.
Dr. DeSalvo. Yes, sir. These include improving efficiency
and business practices at the center, which we have undertaken.
Other actions are beyond our control and include options such
as working with HRSA for community health center programs and
creating ongoing funding for uncompensated care, much the same
way hospitals are supported in the DSH programs.
We look forward to working with you on the ways in which we
can sustain this vital component of New Orleans' recovery.
Thank you.
[The prepared statement of Dr. DeSalvo follows:]
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Chairman Towns. Thank you very much. To the other
witnesses, because we have so many witnesses today, we want to
try to stay within the 5-minutes. We have your written
statements. If there are things that you need to add, you can
possibly add them during the question and answer period.
Thank you very much.
Ms. Bascetta.
STATEMENT OF CYNTHIA A. BASCETTA
Ms. Bascetta. Thank you, Mr. Chairman and members of the
committee. We appreciate the opportunity to be brought together
this morning to discuss the important issues involved in
restoring health care services in New Orleans.
The pre-Katrina health care infrastructure was hospital-
based, very expensive, and yielded generally poor outcomes. As
you know, many low-income and uninsured people traveled
downtown to get their care at emergency rooms and clinics at
Charity Hospital. A better system would be built on a solid
foundation of primary care that would be located closer to
people's homes and would be accessible as their health care
needs arise, that would provide continuity of care over the
long term and that would coordinate care for people with
chronic or more serious conditions who need to see specialists.
Health services research indicates that primary care also
yields better health outcomes at lower costs. So building
primary care in New Orleans became a key priority in the wake
of Katrina, especially for those on Medicaid or without
adequate insurance. My testimony today is based largely on our
July 2009 report on the use of Federal funds to support primary
care in the area. The lion's share of the money, as you know,
is the $100 million PCASG grant. Lesser amounts of Federal
funds were provided through the Social Services Block Grant and
the Professional Workforce Supply Grant, as well as more recent
American Recovery and Reinvestment Act Funds for enhanced
Medicaid payments and additional federally qualified health
centers.
The PCASG was intended to restore and expand access to
primary care, including mental and dental services, as well as
referral to specialty care and ancillary services like
transportation. In addition, the organizations must have had
the intent to be sustainable, that is, to be able to continue
providing primary care after the grant ends in September 2010.
So far, the 25 funded health care organizations have provided
more than 1 million health encounters to over 250,000 patients.
After the storm, provider shortages were a major reason for
disruption in health services. We found that the grant
organizations used the funds to hire and retain physicians,
nurses, and other providers. They told us that this allowed
them to increase access by cutting waiting times and expanding
their hours.
Mental health services were especially hard hit. HRSA's
area resource file documented a 21 percent decrease in the
number of psychiatrists in greater New Orleans between 2004 and
2006, compared to a 3 percent increase in counties nationwide.
Ten of the PCASG organizations hired both medical and mental
health providers to alleviate service gaps, and 15 of 18 we
interviewed for our report on mental health services for
children identified the lack of providers as a significant
barrier.
Other funds were used to renovate or relocate physical
space so that providers could expand capacity through
additional examination rooms and the purchase of new equipment.
Despite the progress made, PCASG organizations face challenges
in establishing a full continuum of care with referrals to
specialists and they are concerned about their long-term
sustainability. Most continue to have difficulties hiring and
retaining staff due to persistent problems with housing,
schools, and the overall community infrastructure in the
greater New Orleans area. In fact, HRSA has designated all four
parishes as a health professional shortage area for mental
health, a designation that none had before Katrina, and most of
the parishes as shortage areas for primary care and dental
services.
In addition, financing poses serious challenges. Although
Medicaid billing has increased and some are able to bill
private insurance, at more than half of the organizations, most
of the patient population and sometimes 70 percent are
uninsured. This is a daunting demographic, given that nearly
all the funding is temporary. Many reported that they intended
to use health center program funding to improve their
sustainability, but with only 16 percent of applicants awarded
grants nationwide in fiscal year 2008, it is unlikely they
would all be successful in obtaining a grant.
LPHI provided a sustainability strategy guide to help them
address a possible $30 million annual shortfall in revenues.
Recipients have completed and planned actions to be
sustainable, but it is not clear which ones will be successful
and how many patients they will be able to serve after the
funds are no longer available. With less than 10 months
remaining, quickly implementing ways to pay for the large
number of uninsured patients will be necessary to prevent
disruptions in these vital services and to prevent the erosion
of gains made in delivering primary care through this grant.
[The prepared statement of Ms. Bascetta follows:]
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Chairman Towns. Thank you very much.
Ms. Craft-Kerney.
STATEMENT OF ALICE CRAFT-KERNEY
Ms. Craft-Kerney. Good morning Chairman Towns and members
of the committee. I am Alice Craft-Kerney, and I am the
executive director of the Lower Ninth Ward Health Clinic in New
Orleans, LA. I appreciate the opportunity to be here to discuss
the successful partnership of government and community to
deliver health care services to the citizens of the New Orleans
region.
I want to first express my appreciation for the Primary
Care Access and Stabilization Grant, which has been a lifeline
for the uninsured and under-insured residents of the greater
New Orleans area. The grant has enabled the Lower Ninth Ward
Health Clinic, as well as other health clinics, to employ
medical staff and provide health care services in New Orleans
which has been designated, as we said, as a medically under-
served area. It is my hope that Congress will recognize the
critical need for our health clinics and take action to
continue this fruitful collaboration which contributed
significantly to the recovery of the greater New Orleans
region.
Before Hurricane Katrina, I worked as a nursing supervisor
at Charity Hospital in the trauma surgery wards. During that
time, I observed many patients that were not insured. And the
reason why they were there is that they did not have access to
primary health care services. These were unnecessary
hospitalizations. But to understand fully what is going on, you
have to understand that community, which was most impacted by
Katrina. You have to understand that this population was very
vulnerable and they had poor health outcomes because there were
large numbers of New Orleans residents living at the poverty
level. There was low education levels and high illiteracy
rates. There was a high dependence on the public sector for
health care needs. There were high rates of chronic illnesses,
high numbers of, as I said, uninsured residents. And the use of
the emergency room was substituted for primary health care.
And there was an inadequate emergency preparedness. And on
August 29, 2005, these factors collided with the worst natural
and man-made disaster in the history of the United States,
creating a public health crisis of enormous proportions.
Ms. Patricia Berryhill, a registered nurse, and my
colleague, and I decided to confront the crisis head-on by
opening the Lower Ninth Ward Health Clinic on February 27,
2007. This was a humanitarian mission that we have undertaken
at the Lower Ninth Ward Health Clinic and it is informed by the
United Nations Guiding Principles of Internally Displaced
People, a standard of care that is supported by the U.S.
Government to ensure the recovery of people around the world
who have become displaced by a disaster.
Principle 19 of the Guiding Principles calls for
comprehensive medical care and special attention to the health
needs of displaced persons. For displaced New Orleaneans, these
health needs involved the traumatic experience of the disaster
and being uprooted from homes, as well as the physical impacts
of not having access to life-sustaining medications and
treatment. As time passed, no one came to the Lower Ninth Ward,
a community separated from the rest of the city by a waterway
called the Industrial Canal, and historically the Lower Ninth
Ward was the last to obtain any services.
With that knowledge, we opened the Lower Ninth Ward Health
Clinic in order to improve medical care needed by internally
displaced people returning to New Orleans, many of whom have a
history of inadequate medical attention.
Initially, the clinic was staffed by volunteer medical
providers at a time when many medical professionals who lived
in the city were physically displaced by the disaster. It was
largely through the Primary Care Access and Stabilization Grant
that we were able to access the funds to employ and stabilize
the medical staff, purchase medications, medical equipment and
supplies, and contract services for laboratory tests. The grant
also provided us with the capacity to raise funds from other
sources.
Today, the Lower Ninth Ward Health Clinic is proud to
report that it employs two part-time physicians with
significant medical experience, two medical assistants, one
clinical director, and one executive director. We serve more
than 2,200 patients on an ongoing basis and over 5,000 patients
through initial medical visits. We are grateful to provide a
service that has not only contributed to the medical progress
and positive health outcomes of our patients, but also to their
recovery and to the recovery of New Orleans.
While we have made incremental progress, there is still
much work to be done in the areas of quality improvement and
disparity reduction. With the adversity of this disaster, there
was also an opportunity to discard ineffective treatments and
try new and innovative therapies to improve quality of care and
reduce disparities. The positive health care outcomes to date
have been realized in large part because of the funding of the
Primary Care Access and Stabilization Grant.
We are eternally grateful to all Members of Congress and
commend past Secretary of Health and Human Services Michael
Leavitt for his service and his leadership as well as his
insightful actions, which aided the New Orleans region in
receiving much-needed funding for health care services. We are
looking forward with great anticipation to future public-
private collaborations which enhance and sustain the health
care status of citizens of our region.
We are at a pivotal moment in the evolution of providing
excellent health care services. We must not forget we have an
opportunity to change the trajectory of internally displaced
people. We are now positioned to do phenomenal things to
improve the health and welfare of the people of New Orleans and
the Gulf Coast region.
Thank you.
[The prepared statement of Ms. Craft-Kerney follows:]
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Chairman Towns. Thank you very much for your statement.
Dr. Erwin.
STATEMENT OF DONALD T. ERWIN, M.D.
Dr. Erwin. Good morning. I would like to thank the chairman
and members of the committee for their continued interest in
the health care situation of post-Katrina New Orleans and for
the opportunity to appear here today.
I am Don Erwin, CEO of St. Thomas Clinic, which is No. 54
on the map that you have. It was started in 1987 as a
community-based clinic in one of the country's oldest housing
developments. Prior to Hurricane Katrina, the focus was its
neighborhood and our programs were defined by the availability
of public and private grants. The budgets were small, services
were limited. After Hurricane Katrina, through the generosity
of many, the clinic reopened to provide health care for
returning citizens and has since become one of the community's
largest and most comprehensive primary care centers.
With the PCASG funds, St. Thomas has gone from 2.4 FTE
providers to 8 primary care and mental health care providers.
We now have a staff of 45 people and an annual operating budget
of $4.5 million. We have a patient base of 14,000 patients and
provide over 22,000 patient visits per year. Although we use an
open access appointment model, we are still not able to meet
the need. Prior to Katrina, we saw patients from three to five
local zip codes. Last year, we saw patients from 251 zip codes
in three States.
In addition to primary care, collaborations have been made
to provide our patients with specialty care in seven major
medical specialties. This specialty care, offered in a primary
care setting, provides coordinated patient-centered care in a
cost-effective way. We are also a training site for medical
students, residents, and nurse practitioners.
As part of a CDC-sponsored national breast and cervical
early detection program, administered by the LSU School of
Public Health, St. Thomas provides breast cancer early
detection with digital mammography and ultrasound. For over a
year after Katrina, we were the only mammography site for
uninsured women and we continue to be one of only two in the
region. Through a unique collaboration with Ochsner Clinic
Foundation and the Association of Black Cardiologists, St.
Thomas offers interventional cardiovascular care for the
prevention of heart attacks, stroke, and sudden death. For
uninsured patients, this cardiovascular care is generally
unavailable or delayed for months.
Included in my written testimony is a copy of a cardiac
tracing that shows an implantable defibrillator operating to
serve the life of a 52-year-old working man who has a wife and
two children. He was at work when he had an episode of silent
ventricular fibrillation and the defibrillator saved his life.
Although these defibrillators cost $50,000 each, we have
installed 14 of them in uninsured patients, with both the
defibrillators and the cardiologists' time being donated to St.
Thomas. I would like for you to understand that this man is
just one of the many thousands of lives that have been saved by
this grant and the services provided.
All of the specialty services that we have available at St.
Thomas are offered to any patient of any of the safety net
clinics in the New Orleans community. As a result of the
infrastructure made possible by the Primary Care Access and
Stabilization Grants, St. Thomas has become a federally
qualified health center and also a level 3 patient-centered
medical home, recognized by the National Committee for Quality
Assurance.
We were recently notified that St. Thomas would be honored
by the National College of Physicians, the second largest
physician group in the United States, which is this year
awarding St. Thomas its Rosenthal Award for the original
approach to the delivery of health care in a way which will
increase its clinical and/or economic effectiveness.
Although St. Thomas has become a federally qualified
center, the annual FQHC grant of $650,000 makes up only 14
percent of our annual $4.5 million budget. We are unable to
take full advantage of the augmented FQHC Medicaid rates, since
only 14 percent of our patients have Medicaid; 72 percent of
our patients remain uninsured. Although the percentage of
Medicaid-eligible patients will increase in the future, we
think this will take at least 2 years.
Without the funds provided through the Primary Care Access
and Stabilization Grant, it is difficult to project continued
viability for St. Thomas. Although we are steadily moving
toward sustainability, with 72 percent uninsured patients, we
do not expect to have replacement revenue to support our
operations until there is expanded Medicaid eligibility.
Certainly an early consequence will be the loss of the
infrastructure necessary to support the policy and procedure
requirements to remain a federally qualified health center and
a patient-centered medical home.
In our business plan, for 3 years, we project that in the
beginning of year three, we could replace the revenues lost by
the Primary Care Access and Stabilization Grant. In the
intervening 2 years, however, we cannot identify any source of
adequate support, nor do we see any other safety net site in
our region which would absorb our patients. As you have heard,
Hurricane Katrina created a new population of uninsured
patients when the storm took people's homes, jobs and health
insurance. The PCASG has enabled us to begin the restructuring
of the delivery system in our State.
We are optimistic about the sustainability of clinics like
St. Thomas, if we are given another 2 or 3 years for the
recovery to continue. But for the present, if there is no
bridge funding, we anticipate that our patients will find
themselves in the same situation they found themselves
immediately post-Katrina, where the only source of primary care
was the crowded emergency rooms.
Thank you very much for the opportunity to speak with you
this morning and for your continued support of our community.
[The prepared statement of Dr. Erwin follows:]
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Chairman Towns. Thank you very much for your statement.
Mr. Griffin.
STATEMENT OF MICHAEL GRIFFIN
Mr. Griffin. Good morning Chairman Towns, Congressman Cao,
and other distinguished members of the Committee on Oversight
and Government Reform. I would like to thank you for allowing
me to offer testimony in this public formum on ongoing health
care concerns and challenges facing the New Orleans region
post-Hurricane Katrina.
My name is Michael Griffin. I am the chief executive
officer of Daughters of Charity Services of New Orleans, a
primary health care provider whose organization has roots in
New Orleans for 175 years, with services to the poor and
vulnerable. The Daughters of Charity Services of New Orleans
[DCSNO], is sponsored by Ascension Health. Ascension Health was
founded in 1999 with the Daughters of Charity and the Sisters
of St. Joseph joining their health ministries into one
organization.
DCSNO's mission is to improve the health and well-being of
our community. We are dedicated to providing primary and
preventive health care services which address the needs of the
total individual--body, mind and spirit. I welcome this
opportunity to inform you on how the Primary Care Access and
Stabilization Grant program has assisted us in restoring and
improving the health delivery system in New Orleans and what
challenges are still before us.
When Hurricane Katrina struck the city of New Orleans on
August 29, 2005, it severely impaired the health care delivery
system. Medical and other support personnel were displaced and
the city lost several hospitals and numerous primary care
providers. DCSNO was not sheltered from the impact of Hurricane
Katrina. We lost our one and only health center site to
flooding in the aftermath of the storm. Yet as our history
demonstrates, the DCSNO board and Ascension Health would remain
steadfast and committed to serving the poor and vulnerable in
New Orleans. Within 45 days after the storm, we opened a new
health center in the Metairie area, next door to the Department
of Health. However, the diminished capacity of the overall
health care infrastructure in new Orleans severely compromised
continuity of care for low-income and minority populations who
were attempting to remain or return to the area.
Katrina resulted in the loss of five hospitals, one of
which served the vast majority of the medically under-served
and poor. The aftermath of Hurricane Katrina was the litmus
test which challenged DCSNO to improve access to health care
services at additional locations throughout the metropolitan
area with the goal of meeting the primary care needs of the
community at large. It was because of the Primary Care Access
and Stabilization Grant awarded by the U.S. Department of
Health and Human Services and authorized by Congress that DCSNO
was able to rapidly expand from one to three primary health
care centers in the area. Today, these health care centers are
current in providing primary care services to the under-served
populations in the Carrollton area, the Upper Ninth Ward, and
Metairie.
As a direct result of PCASG funding, DCSNO has been able
this past year to provide affordable or free care to 20,034
patients, totaling 65,509 patient visits. Seventy-two percent
of those patients are uninsured. Let me repeat that: 72 percent
of the 20,000 patients are uninsured. Fifteen percent are on
Medicaid, 5 percent are on Medicare, 7 percent are on other
insurance. DCSNO has experienced unanticipated growth in this
last year of a 49 percent increase in our patient population
since last July.
The Primary Care Access Stabilization grant funding allowed
us to retain and hire new doctors. We are offering free
pharmacy services and have expanded access to mental health
providers for both children and adults. We have plans to expand
dental care and optometry. In addition, we have leveraged the
PCASG funding to encourage partners like the Unity Foundation
and the March of Dimes to help fund mobile primary care units,
two of which are mobile prenatal units and the other is one
that treats the homeless, and to restore our Seton Resource
Center for Adolescent and Mental Health Development that offers
behavioral health and counseling services at 10 public and
parochial schools.
Let me quickly tell you this story. An uninsured mother,
who didn't have a regular physician, recently attended a health
fair staffed by DCSNO's mobile unit. She had a history of
hypertension, cholesterol, and glucose issues. While having her
testing done, the woman expressed concerns to her medical
provider about her daughter complaining of not feeling well.
She was constantly drinking water and going to the rest room.
She wondered if we could just take a quick look at her
daughter. We gave the 9-year-old a glucose test and found that
the glucose level was above 300, which was extremely dangerous.
Our clinician recommended that the mother immediately take her
child to Children's Hospital for further treatment. The child
was in fact admitted to Children's Hospital, where the
emergency room doctors informed the mother that any prolonged
high blood sugar could have resulted in a stroke, coma or even
death.
I tell this story because it demonstrates the type of
community that we are doing at Daughters of Charity Services of
New Orleans to help those who do not have health insurance and/
or a family physician to call when a child gets sick.
I thank you, Chairman Towns, for this opportunity to
testify before Congress, and thank you for your support of New
Orleans.
[The prepared statement of Mr. Griffin follows:]
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Chairman Towns. Thank you very much, Mr. Griffin.
Dr. Townsend.
STATEMENT OF ROXANE A. TOWNSEND, M.D.
Dr. Townsend. Thank you Mr. Chairman and members of the
committee for the opportunity to address you today regarding
the status of health care in New Orleans on behalf of the
Louisiana State University health system.
In addition to my role at the health system, I also have
the privilege right now of serving as the interim CEO to the
public hospital in New Orleans.
When Hurricane Katrina forced the closure of the Medical
Center of Louisiana at New Orleans, we did lose critical
infrastructure for health care. We lost 550 inpatient beds. At
that time, we were doing 23,000 patient admissions a year, we
had 120,000 emergency department visits. But something that is
not often recognized and is really important, we did more than
260,000 outpatient clinic visits in our hospital-based clinics.
That included primary care as well as specialty care.
We had over 640 medical residents and fellows from
Louisiana State University and Tulane University training at
that hospital, along with thousands of other students, dental,
nursing, and allied health, and pharmacy. It was a critical
area for teaching for Louisiana, for the work force, for the
future. We lost all of that in Katrina. And when you look at
that, the role of that facility, it wasn't simply for the New
Orleans region. It was a Statewide resource, where people who
were uninsured could go to get specialty care. Oftentimes the
specialty care isn't available to these folks, even if they
have a Medicaid card in the rest of the State. We lost all of
that from Katrina.
Knowing the important role that this facility played, I
consider these people who stayed there during the storm and
reconstituted services after as really true heroes. They went
from constructing tents in a parking lot where they continued
to provide services; they moved those tents into the convention
center because it didn't flood. So they at least had a roof
over their head.
Then they moved those tents into a former department store
in a mall adjacent to the Superdome once the flooding subsided.
And we continue to do specialty care and primary care clinics
there today, because it wasn't until November 2006 that the
former University Hospital campus was able to be transformed
and reconstituted into an inpatient facility. That was through
the work and collaboration of FEMA and LSU, as well as
Louisiana's Office of Facility Planning and Control. Today we
are operating 275 beds, about half of what we had before the
storm. With that, we are running close to 85 percent occupancy.
If you look at hospitals across the country, 85 percent
occupancy is full. In our ICU, we have 36 beds. They stay full
all the time. We have 38 inpatient acute psychiatric beds for
adults. They are always full.
We also provide the only Level I trauma center in
Louisiana, serving a nine-parish area. We have 11 operating
rooms, less than half of what we had before the storm. One of
those always has to be on standby for trauma, since we are
Level I. So we are cramming all of our operating room cases
into 10 operating rooms in that facility.
And as a well-respected physician in the community, someone
who was there during the storm and after the storm said, we
really are gaining stability but we are still pretty fragile.
We are probably one big bus wreck away from just crippling the
entire system down there. So we still have a way to go.
One of the really exciting things that did happen was
through the generous funding of Congress we got the Primary
Care Access and Stabilization Grant. So we were able to bring
six community clinics up after the storm associated with in the
interim hospital. And this was different from before the storm
where everything was pretty well located on campus. Now these
six clinics are allowing quality patient care to happen close
to where people live. And the quality is evidenced by the NCQA
actually giving us recognition status as patient-centered
medical homes in those community clinics.
The grant funding was flexible enough that we were also
able to provide some specialty care services. As we look at
this funding coming to a close, we recognize that our role as
an academic medical center is to support these primary care
clinics. So we are looking at consolidating some of those
clinics into bricks and mortar, rather than the temporary
buildings that they are in now. But we see that access to the
specialty care and inpatient care is extremely important. So we
are trying to partner with the community clinics that are still
there that will hopefully survive after the primary care grant
goes away, so that we can give important services to those
folks. We don't just treat, we also educate. And we have to do
both of those together.
So I thank you for the opportunity to address the committee
today.
[The prepared statement of Dr. Townsend follows:]
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Chairman Towns. Thank you very much.
Dr. Rowland.
STATEMENT OF DIANE ROWLAND
Ms. Rowland. Thank you Mr. Chairman and members of the
committee. I am Diane Rowland, executive vice president of the
Kaiser Family Foundation, and since Hurricane Katrina I have
helped lead the Foundation's efforts to document the needs and
monitor the progress in New Orleans through two city-wide
surveys of New Orleans residents in 2006 and again in 2008. We
are also planning our third survey in 2010, just to be able to
assess how the progress has been going.
All of our work underscores the importance of building a
strong health care system to meet the needs of all the
residents of New Orleans as part of making New Orleans again a
vital and dynamic system. You have heard from all of our
witnesses of the fact that New Orleans did not have a fully
operating system even before Katrina. And you have heard about
the devastation that Katrina wrought on the city and on its
health care system.
But the devastation was so widespread that it also brought
an opportunity to establish and design a better system, with
community-based services and integrated services for the poor
and uninsured, instead of a system based on a hospital and
disproportionate share Medicare payments to help sustain it.
The public returning to New Orleans had many of the same
problems of the public that left New Orleans. Many were poor
and uninsured and many with chronic health problems. So Katrina
did not wipe away the problems of the residents of New Orleans.
Adequate medical care, rebuilding medical capacity, and the
Charity Hospital system establishing care in clinics and
neighborhoods were high priorities of the residents that we
surveyed, and came in next after rebuilding the levees which as
you might imagine would have been their major concern. And as
we look at a redesigned health care system we need to look at
the major elements that need to be put in place. First and
foremost, health care coverage provides the means for people to
access health care services and the financing to support a
health care system. For children in New Orleans, there is a
success story. Today, only 8 percent of New Orleans' children
are uninsured, lower than the national average. This is due
largely to the expansion of coverage through Medicaid and the
LaCHIP program. Today in the city of New Orleans, over half of
the children have Medicaid as their source of coverage, which
helps account for the lack of a large uninsured population.
But for adults in New Orleans, the story is very different.
Louisiana, among the poorest States in our Nation, one in four
living in poverty, has one of the most meager programs in terms
of eligibility for adults. In fact, a working parent cannot
qualify for the Medicaid program if their income is over $5,513
a year, or 25 percent of the Federal poverty level. No coverage
is available for childless adults and those who are in the city
now. We account that 29 percent of non-elderly adults are
uninsured. These are the same levels of lack of insurance for
adults as before Katrina, and these are the very individuals
who are now seeking care through the community clinics that
have been developed, and will need care in an ongoing manner
until insurance coverage is made available. Attempts to improve
coverage have been stymied, leaving these developing health
systems to care for the largely uninsured adult population.
Seventy-two percent uninsured is an unsustainable level of care
to be delivered in even a grant-supported clinic.
And the good news, though, is that the community-based
system of clinics for primary care has been able to at least
develop with the support of the Federal grant funds. It is
decentralized, it is in the neighborhoods where people live. A
forthcoming Commonwealth Fund study that is evaluating these
clinics has found that the patient experiences show very
promising results on quality, on access and on efficiency for
these clinics. The investment in these clinics has helped to
move a new model of care to the city of New Orleans, and
appears to be bringing much-needed care to the city's still
substantial uninsured population.
But the bad news is that the future sustainability of these
clinics is in jeopardy, largely due to the lack of coverage.
And while we all talk today about national health insurance and
universal coverage as part of the health reform efforts, those
efforts are still not going to be phased in if enacted until
2013 or 2014, leaving a huge gap right now for these clinics to
be able to continue. In order to provide them with the support
they need, coverage needs to be expanded, many need to be able
to become federally qualified health centers, and there needs
to be continued support for the uncompensated care that they
provide to individuals who are uninsured.
Even in the models of community health centers around the
country, we see that the mix of revenues that support them is
grant funding from the Federal Government combined with the
payments for their insured patients through the Medicaid
program. And finally, a fully integrated health care system
requires specialty care and tertiary care capacity, as you have
just heard. So reestablishing a teaching hospital with multi-
specialty care to back up the clinics is equally essential.
Without improved coverage of adults, combined with
financial coverage for the uninsured, the neighborhood primary
care model will falter, not in the care it delivers, but in its
ability to sustain operations. Yet this is a critical building
block for the future of New Orleans' health care and a critical
building block as we look toward national reform. I hope this
hearing will help to shed light on the needs of these clinics
and the ability to provide services to the uninsured and the
low-income population of New Orleans.
Thank you for this opportunity.
[The prepared statement of Ms. Rowland follows:]
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Chairman Towns. Thank you very, very much. Let me thank all
of you for your testimony. You have been very helpful.
Now we are going to the question and answer period. I will
start by first asking you, Ms. Bascetta and Dr. Rowland, what
would it mean toward the region's overall recovery to lose
these services that have been described so eloquently here this
morning?
Ms. Bascetta. I think that most importantly, the threat of
backsliding on the progress that has been made so far in the
primary care foundation is something that we would not want to
see. These clinics now and this primary care foundation that
has been built is in an expanding mode. It is in a growth mode.
And reverting back to a less effective system where people
would have to seek care in an emergency room would be more
expensive and would yield poorer outcomes, as you have heard.
In addition, like emergency rooms throughout the country,
they are already at capacity. So it would be very dire to lose
these primary care clinics.
Chairman Towns. Dr. Rowland.
Ms. Rowland. Mr. Chairman, I know your concern is for the
people of New Orleans. I think what these clinics have
demonstrated is that they need access to care. There are severe
gaps in their ability to get the care they need. We know that
uninsured people get less care than those with insurance and
that they live sicker and die quicker. So I think it is an
investment not only in the clinics themselves but especially in
improving the health care of the people of New Orleans. And
many of the low-income population there suffer from multiple
chronic conditions that are not readily available to emergency
room care. So I think you really need to have in place a good
primary care network and to sustain it.
Chairman Towns. Right. Thank you very much.
Let me raise this question with you, Dr. DeSalvo, Ms.
Craft-Kerney, Dr. Erwin, and of course, Mr. Griffin. As you
know, the grant ends next year. What Federal assistance are you
now seeking to be able to keep it going, just sort of run down
the line real fast as to what you're doing to keep this alive.
What are you doing?
Dr. DeSalvo. What we have done is work toward improving
efficiency, quality, so that we are providers of choice for
communities, irrespective of ability to pay. We work
collaboratively with organizations like 504 Health Net to
ensure that we are sharing best practices, billing when
appropriate, etc. So we are doing our best to be efficient
operations.
The reality is, as you heard, that can only go so far,
including when patients contribute to their care, which they
do. We charge sliding scale fees at these sites. And so the gap
will need to be filled in much the ways that hospitals have a
gap filled for uncompensated care. It is just the DSH program
doesn't support primary care federally in the way that it
supports the hospital systems.
So in terms of gap, it may be additional appropriation, it
may also be just thinking about ways that we can use existing
funds that we have, for example, CDBG funds that we got for
recovery are now at the LRA to, that are for urban renewal,
principally for housing, but thinking about the fact that
without health care, it doesn't make a lot of sense to just
build housing, you have to have the fabric. So that is one
opportunity for bridge funding, and then to think about whether
we want to use a waiver for disproportionate share money to
support the clinics going forward, until it is not needed,
because there is coverage for everyone.
Chairman Towns. And right down the line.
Ms. Craft-Kerney. The Lower Ninth Ward Health Clinic is
moving toward sustainability by first, making sure that we are
Medicaid providers, Medicare providers, and private insurance
providers. We came up a little bit differently, because we came
up post-Katrina, truly a grassroots effort. So we are putting
those different things in place, so that we can become more
sustainable. Also, we are looking to the philanthropic
community to assist us.
Chairman Towns. Dr. Erwin.
Dr. Erwin. St. Thomas is a federally qualified health
center, and as such, get Federal funds from that. As I
mentioned in my testimony, the financial base that is required
to maintain the infrastructure, so that you can comply with the
policies and procedures and the 24 hour coverage and that sort
of thing, we are working hard to try to maintain it.
We have a sliding scale, we have increased our patient
revenue money, funds from patient revenue, from zero 2 years
ago, 3 years ago, to an estimated $420,000 this year. The mayor
of New Orleans has also granted us $850,000 for CDBG funds. But
this is a one time only thing.
We have a $2 million allocation from the State, but that is
for capital improvements only. So we have to stay viable in
order to be able to capitalize on that. Our staff meets weekly
and we go over ways that we can improve our sustainability, not
only with grants but by watching our costs as carefully as we
can. And we have unfortunately with the 72 percent uninsured
population, it is just very hard for us to find any kind of
viable revenue that could replace this money until there is
some expansion of Medicaid.
We are told that there will be a substantial increase in
patients eligible for Medicaid, but this will likely take 2
years. That is why in our sustainability projections we
estimate that beginning year three, should this occur, the
beginning of year three St. Thomas will actually be able to
replace the $3 million that we would lose from the Primary Care
Access and Stabilization Grant.
We expect to be self-sufficient in year three on the
business plan. As I say, we charge everyone that can pay. There
is a sliding scale and we ask the patients to take
responsibility for helping us be viable. But when we are
dealing with a demographic of 72 percent uninsured, it is
really hard.
Chairman Towns. Right. Mr. Griffin, briefly, because my
time has expired.
Mr. Griffin. Daughters of Charity is focused on the growing
uninsured population, as we are 72 percent uninsured. Since
Katrina, we have blindly accepted all who come. And that has
been majority adults who do not qualify for Medicaid or
uninsured. So we are 72 percent uninsured, we are focused on
growing our Medicaid, Medicare, and insured populations. We
also are evaluating our expenses and looking at our care
management model, which is pretty comprehensive, seeing how we
could be more efficient. And also looking at fundraising.
Chairman Towns. Thank you very much. My time is expired. I
now yield 5 minutes to the ranking member, Congressman Issa,
from the great State of California.
Mr. Issa. Thank you, Mr. Chairman. The great State of
California is $140 billion or whatever, upside down at any
given time, actually it is $47 billion right now, they have
narrowed it. We are a State that taxes at a rate more than 25
percent higher than Louisiana, and we have overspent. We
provide a lot more public health assistance in California in
many areas than Louisiana does. And I guess, Mr. Cao, who of
course is one of your representatives, will probably look more
specifically into a lot of what can be done and what can be
delivered from the Federal Government. But my questions are
going to have to be a little more tough love, not just because
I am personally a conservative, but because I have an
obligation to California, in addition to the Constitution.
Louisiana's top tax rate is 8.4 percent, California is 10.4
percent. You have a 4 percent sales tax, we have an 8.25
percent sales tax. I know you are all health care
professionals. But in spite of this, is everyone so poor in
Louisiana that in fact the State cannot do more for you? Are
you going to be a permanent ward of the Federal Government?
Because when I hear sustainability counting on Medicaid
increases, when I hear Mr. Griffin saying, ``well, we take
everyone, including those who are not poor enough to qualify
for Medicaid,'' then I am extending Medicaid past what we
define as the poor.
So let me ask you much more the other part that I didn't
hear. What is your State, and we will have a second panel from
your State, but what is your State doing to bring all the
powers to be of the State, including finding funding sources
for you besides simply the Federal Government? Because
obviously the direct effects of the levees breaking, even if we
put them all on the Federal Government, at some point that is
paid out. Then we ask the question of what is going to make you
a sovereign State, meeting your own obligations.
And Dr. DeSalvo, only because I can see that you are
saying, how is this guy asking a doctor this question, would
you help me with this? Because I know that all of you look to
all sources of revenue. You are doing a lot to build better
doctors and better health care. But I have to ask in the long
run, what are you doing besides coming to us? And don't get me
wrong, Mr. Cao is absolutely dedicated to making sure we do
everything we can do. But if I could ask each of you that same
question, it is really my only question for the panel. Because
I see all of you as doing the right things within the structure
that exists. You are getting money from all revenue that you
can find, you are building great solutions for people who come
to you. And I don't have any quibble with that. I totally see
that.
But I will start with Dr. DeSalvo, because this is a
question that a California Member has an obligation to ask, in
addition to a Louisiana Member, who is obviously going to say,
we have to do more. Please.
Dr. DeSalvo. Thank you for the question. I will begin with
the concept that, when the Federal levees failed and our city
was destroyed we began very early to work together to think
about how we would rebuild this. And in education, for example,
there has been creative thinking, just like there has been in
health care.
We did not as a community of stakeholders and health care
providers think that there was going to be some manna from
heaven that was going to fall to make it happen. And indeed, as
Alice describes, and I tried to as well, and others, it is very
grassroots, this clinic system.
Mr. Issa. I am totally supporting that.
Dr. DeSalvo. I am going to get there.
Mr. Issa. Where is Louisiana coming in and how are they
going to help New Orleans? Because you are a State first.
Cities are not actually directly recognized by the Federal
Government. We recognize States. We are the United States of
America, and in a sense, only States come to us. And when the
next panel is up, I am going to be asking them that same series
of tough questions, what is the State doing to be equal in its
support of its people to other States.
Dr. DeSalvo. Yes, sir. So I will skip the tax policy,
because I really cannot answer the question. But what I wanted
to tell you is that the past 4 years, the community has come
together at policy tables, Democrats, Republicans, maybe
Independents, who knows, to think about ways that we could
finance this kind of system. We have developed at least three
discrete plans: one, the redesigned collaborative that was a
mix of private coverage; another which was an affordable health
insurance plan through private coverage solely, called COLA;
and another one that was a waiver that went in about a year ago
to the Feds to use disproportionate share to recover to shift
the funds. Money we already get, but use it in a different way
that requires Federal support.
So I will just say that we have been working incredibly
hard in Louisiana, across party lines, through two Governors,
and have always come up with the same idea as a State: this is
what we want to see happen. We need to figure out how to
finance it. At this point, I can't speak on behalf of the
State, but there are some things that do need to happen
federally to allow us to move forward as a State, i.e., waivers
for how we use disproportionate share money, how we might use
the existing recovery authority money that we got for urban
renewal that might require some congressional action to allow
it to be for urban rebuilding.
Mr. Issa. Anyone else that can answer as to just what you
see your State doing? Because Bobby Jindal was a colleague of
ours, a friend of mine, and I want this committee and all the
committees to work hand-in-hand with your Governor, to enable
those things. But we are going to have to ask them the same
tough question I am asking you. So if any of you have an answer
to that narrow question of how Louisiana is working to meet
this sustainability requirement that you all talked about. Yes,
Dr. Townsend.
Dr. Townsend. I obviously can't answer for the State, I
don't sit in that role. But I think when you look at how health
care is funded, there are really only three pots of money. And
perhaps it is only two. I mean, there is Federal money, there
is State money, or there is private sector money. So I think
one of the things that the State is trying to do is economic
development. Because if you have an employer who offers an
insurance plan, then you have access to insurance that the
Federal Government doesn't really have to participate in, nor
does the State. So I think that is one of the ways. We have to
improve our education, we have to improve our employment, so
that people have access to health care programs that don't
necessarily have to be funded by tax dollars. So I think that
is one of the things that is happening.
And then I think Dr. DeSalvo talked very eloquently about
the other kinds of waivers and ideas for current funding, not
to increase it but to have more flexibility in current funding.
Mr. Issa. And I know we would like to do that. Mr.
Chairman, I thank you for your indulgence. I am sorry we can't
continue this, but I assure you, we will be trying to work
together with Mr. Cao to make those waivers happen as your
State sees fit. Thank you.
Chairman Towns. I now call on a very active member of this
committee, of course, Mr. Cummings from the great State of
Maryland.
Mr. Cummings. Thank you very much, Mr. Chairman, and I want
to thank all of you for what you do every day to address the
needs of so many people. You don't have to say it, I will say
it, I have listened to your testimony, these folks have been
left behind. Let's not kid ourselves. You all are doing the
best you can with what you have. And in answer to Mr. Issa's
inquiry about tough love, you can have tough love and die. And
you have not provided the testimony yet, but we have just spent
a lot of time in the House addressing this issue of health care
overall. And the statistics show, and the research shows, that
some 45,000 Americans die every year because they don't have
insurance. Other research has shown that 1,000 children die
every year because of no insurance.
So the question is, where does the tough love, how far do
you go with the tough love if people are dead? So let me ask
you this. This committee, Mr. Chairman, we had some testimony a
while back, and the Members will remember this, where we were
talking about formaldehyde in trailers, where folks were living
in trailers getting sick, big time. And this was a while back.
This committee pushed hard to get the folks out of trailers.
I just wondered if any of you all can comment on that.
Where is that? Because a lot of your work would be made even
harder. When they told us about the ailments that resulted from
folks breathing those fumes, it was quite devastating and we
were very upset. I just wonder, where does that stand? Can one
person just tell me about that? Just one. Somebody please, my
time is running out.
Dr. Erwin. I will just take a stab at it. We still see
patients who are living in trailers, and we still see patients
who are exposed to formaldehyde. The problem as we perceive it
is there is just not adequate housing for them to get out of
the trailers.
Mr. Cummings. So housing is still not adequate, is that
what you are saying?
Dr. Erwin. No, sir, it is not.
Mr. Cummings. And I think going back to what you said, Dr.
Townsend, you were talking about, when you were answering Mr.
Issa's question, you talked about the whole issue of people
living, being able to have jobs and so forth and so on. What I
said from the beginning was a lot of people have been left
behind. I don't know how many people on this panel have visited
the Ninth Ward, probably all of us, and visited New Orleans to
see even to this day areas that have not seemingly been touched
that were destroyed.
And I am just wondering, you all talked about the three
different areas that funds could come from. First of all, do
you think that you are doing the best that you can with the
funds that you have? Dr. Townsend, don't be shy.
Dr. Townsend. Yes, sir, thank you. I do think that everyone
is making a concerted effort to wisely use these dollars to
make sure that we provide the best care for the most people in
the most efficient way. I think that is happening right now.
Mr. Cummings. And you said something about you have one
half of the beds but 85 percent capacity, is that what you
said?
Dr. Townsend. No, sir. I have about 50 percent of the beds,
but capacity----
Mr. Cummings. Fifty percent of the beds that you had before
Katrina?
Dr. Townsend. That we had before the storm. But we are
providing about 60 percent of the inpatient services. So even
in the inpatient setting, we have become more efficient and
cost-effective. And in the outpatient setting, we are about 80
percent of the outpatient capacity that we were before the
storm. We are doing about 80 percent of the visits that we were
doing before the storm.
Mr. Cummings. An area that I am very interested in is
dental care for children. We had a little boy in my State who
died, Deomonte Driver. He was on Medicaid, but he died at 12
years old because the tooth infection that would have cost $80
to repair went to his brain and he died at 12. I am wondering,
Ms. Rowland, you talked about children, only 8 percent of
children are uninsured, but how are we handling our children
with regard to dental care? What is going on there?
Ms. Rowland. Well, as you know from the case in Maryland,
dental care is very limited, even under the Medicaid program.
It is a covered benefit, but very few dentists participate. So
I think that is one of the areas that really has to be
supplemented and helped in all the States, as well as
Louisiana.
Mr. Cummings. How are we doing in your State? That is what
I want to know?
Ms. Rowland. I think that dental care speaks to the broader
issue of how this community of health providers is working
together to cover the territory. So for example, some of the
dental care is provided in mobile medical units by some of the
organizations in this. They have created a Web site with a map
and a grid that will tell providers where people can go for
dental care on any given day. Charity Hospital has reopened its
dental care services. Daughters of Charity will have dental
care services.
But we are not going to replicate that if we are just a
couple of miles apart. We are trying to be very responsible
with the funding to make sure that there is access to services.
Mr. Cummings. Thank you very much, Mr. Chairman. I see my
time has run out.
Chairman Towns. Thank you very much.
I now call on the gentleman from Louisiana, Congressman
Cao.
Mr. Cao. Thank you, Mr. Chairman, for this extremely
important hearing. I know fully the health care needs of the
district. But before I begin addressing those questions, I
would like to ask Ms. Bascetta, do you see any instances of
waste, abuse, or fraud from the Federal money that was
channeled down to the area for rebuilding purposes, especially
in regard to the health care system?
Ms. Bascetta. We have not specifically scoped our work to
look at fraud, waste, and abuse. But in the course of our work,
we did not see any of that ourselves and we didn't hear about
that from any other organizations, the IG, or anyone else.
Mr. Cao. So based on the information that you have received
so far, they have used the money responsibly?
Ms. Bascetta. That is right.
Mr. Cao. Dr. DeSalvo, I know that you are in charge of
Tulane community-based health clinics. How have you seen the
increase in clinics help address the issue of the uninsured,
and whether or not this is a model that we should be looking at
as a Nation in order to cut down the health care costs that we
are struggling with, trying to address?
Dr. DeSalvo. The goal is to get people to go to the right
place at the right time for the right care, because that is not
only better quality, but it is more cost-effective. And primary
care is usually the best place for people to go. Clearly,
emergency rooms and hospitals are a necessary part of the
continuum. But all things considered, like the man I described
in my testimony, he is better suited, with his high blood
pressure and his gout, to be treated in primary care where it
is about a quarter of the cost than the emergency room.
And there is a fair number of people in Louisiana who fall
into this gap. They would not qualify for Medicaid, even being
quite poor. If they don't have children, they wouldn't qualify.
But most insurers in Louisiana don't offer health insurance
that is not affordable. So this is an interesting model, PCASG,
where we have actually taken funds and though they are still
distributed institutionally, we are paid not based on some sort
of, it is a given, we are going to give you the funds, we are
actually paid as organizations to take care of a set
population. There is a high expectation that we are going to be
available for those patients, provide quality care, do it in a
very cost-effective way. We are mystery-shopped, we have
satisfaction surveys, so there is pretty intensive oversight of
our programs.
But I think the PCASG is a really interesting bridge model
for urban markets, in particular that want to move away from
hospital-based funding of care for the uninsured. There is a
gap until there can be universal coverage. But you want to make
sure that you have distributed the funds so that all of your
money is not in one financially consolidated institution or
place.
What we have also learned is that if you pay providers for
quality and value and you give us the opportunity to take care
of populations instead of just paying us for volume, it
naturally leads to team-based care and opportunities for
innovation that I have never experienced before in 20 years of
health care.
Mr. Cao. Dr. DeSalvo and also Dr. Townsend, do you have a
system where patients who show up in your emergency rooms, to
direct them to community-based health clinics?
Dr. Townsend. Yes, we do. At the interim LSU public
hospital, when patients arrive at the emergency room, whether
the care is actually emergency room appropriate or not, if they
are not assigned to a primary care clinic and particularly if
they are uninsured, then we are able to direct them to a
primary care provider in one of the community clinics where
they can access care. We work with them to try to make sure
that they understand how to appropriately access the clinic and
the emergency room when necessary.
Dr. DeSalvo. Tulane Hospital has been touched in a fashion,
of course, by us because we have clinics in the system, but
touched by the leadership of PCASG meaning very specifically
going out and targeting and talking to the emergency room
leadership, the hospital leadership to be certain they are
aware of the program. We update them with flyers and
information about availability. And there is a Web site they
can go to, which I think you have information on, G&O
Community, which will tell you in a zip code what is available,
what the hours are, what languages they speak, and what
services they offer. We have been really aggressive about
trying to get people directed from emergency rooms, when
appropriate, into medical homes so that they don't continue
using that other system.
Mr. Cao. How many more medical community-based clinics do
you see that we will need in the future, in order to address
the needs of the people of the Second District? Another
question to you here is, how, what steps do we need to take
when the Primary Care Access Stability Grants end? What plans
do we have to continue these community-based clinics and to
provide primary care to those who are uninsured?
Dr. DeSalvo. In terms of the number of providers, types and
sites, I think that is a really great technical question that
HRSA can help us with. They have been thinking about that with
some of the providers already. The 91 access points that we
have are really varied in scope and size. Some of them are
small, school-based clinics or mobile units. I certainly don't
want the committee to walk away thinking we have 91 community
health care centers, because we are not there yet. And I don't
know if that is the right number. But it is an important
planning issue we do have to decide. The community certainly
wants to work together to right-size it.
Mr. Cao. What plan do you have in order to continue these
projects once the Primary Care Access grant runs out or ends?
Dr. Townsend. I think what you have heard today is that as
long as about 72 percent of the patients who have to access
those community clinics remain uninsured, then the
sustainability of those clinics I think is really impossible
without an alternate funding source identified. Like I said,
there are really essentially two pots of money. There are tax
dollars and then there is private sector. Other than grants and
philanthropy and things like that, I am not really sure that
anyone is able to identify how we are going to keep this going.
Chairman Towns. The gentleman's time has expired. Now we
will yield, as you know, we have just been called for votes. So
we will try to get at least two more in.
Congressman Tierney from Massachusetts.
Mr. Tierney. Thank you very much. I just want to ask one
particular question. We know that sending children to school in
a healthy State is a good thing. Have you had any examples of
creative use of the educational funds and system, and
cooperation or coordination with the health care system that
have helped you at all?
Mr. Griffin. There have been discussions and work that has
been done. As I mentioned in my presentation, we actually do
behavioral health in 10 schools. We are actively having
discussions with a school system about expanding that. There
also have been numerous efforts and expansion in school-based
health centers throughout the State as well as in the New
Orleans area. That is a more comprehensive provider model that
has medical behavorial health and other services included in
those locations.
So there are, I think approximately nine school-based
health centers in New Orleans and several more in the
metropolitan area. So those efforts are ongoing in
collaborating and coordinating with the school systems.
Mr. Tierney. Thank you. Ms. Bascetta.
Ms. Bascetta. We had a companion report in July of this
year that we issued on the mental health needs of children in
New Orleans. We noted in that report, which I can provide for
the record, that school-based health centers were an important
model in the area.
Mr. Tierney. Thank you. If nobody else wants to comment on
that, I'd like to yield to Mr. Kennedy, who I know has some
pertinent questions he would like to ask.
Mr. Kennedy. Thank you, I thank the gentleman from
Massachusetts.
I would like to ask, for those of you who would answer,
what percentage of those coming into the emergency rooms
exhibit mental health issues and addiction issues? And to what
extent do you attribute any of the PTSD, obviously to the
natural disaster? And if you could, address the issue of the
trauma that was exhibited as a result of the hurricane and to
what extent there was a lack of proper mental health services
available to address the needs of folks. From what I
understand, clearly, trying to get people's mental health needs
met has been an endemic problem. Clearly, the enormous crime
rate in the area now, I kind of feel like our criminal justice
system is a substitute in kind of the last sense for our mental
health system that isn't there.
So I would ask you to comment on the lack of a mental
health system and also what you see as the consequences of that
today in terms of the number of people showing up with mental
health issues in our health care system as a primary source of
issues, and whether you can reimburse for that, given the
exclusion that many insurers have, if people come in with an
accident, that you can't reimburse for it if they have
alcoholism; if they have been drinking alcohol or ingested, as
a result of drugs, that many insurers say they won't insure,
because that is ``a deliberate thing'' and they won't allow you
to get reimbursement for it. If you could comment on any of
those issues.
Ms. Craft-Kerney. Mr. Kennedy, at the Lower Ninth Ward
Health Clinic, we have seen many come in with mental health
problems. We had a young man who was known to us who said, ``I
just want to slit my wrists.'' We had to get him some help
immediately. But we just want you to know that many of the
mental health problems that are taking place, what is happening
is because there was a lack of services initially, and there is
still ongoing problems with the mental health piece, we are at
a point where we are actually diverting and sending people to
the correct places. But initially, there was a big impact and
people are suffering from depression, this underlying
depression. I might be OK today, but tomorrow I might not be.
So you are seeing people who are just very, very fragile.
And we don't know what is going to be the breaking point for
them. So there is ongoing assessment of that depression.
And what I did want to say is that the criminal justice
system comes into place because many times people are below the
radar. I am OK today, but you don't know what is going to
happen tomorrow. So what happens is they become entangled with
the criminal justice system, and what happens is right now our
biggest provider of mental health services, inpatient, is the
Orleans Parish Prison, unfortunately.
Ms. Rowland. Mr. Kennedy, in our surveys of the residents
of New Orleans in 2006 and 2008, the need for mental health
services was quite apparent. But one of the striking things we
found was in 2006, 1 year after the hurricane, people reported
that their mental health status was fairly good, I think
because so much was going on in their lives they didn't really
focus on it. But by the time we came back in 2008, we saw much
higher contact with the health care system, much more
frustration over inability to get the medications they needed,
and today saw that 15 percent of those in New Orleans reported
that they had a severe mental illness, such as depression or
other things. So I think you are pointing out an area where the
population has severe needs. We will be going back in 2010, and
hopefully find better access than we did in 2008.
Mr. Kennedy. Are you integrating mental health to the
``white coat docs?''
Dr. Erwin. I would like to address that, if I could,
Representative. One of the other recipients of the PCASG money
is the Metropolitan Human Service District in New Orleans,
which is the public entity responsible for most of the mental
health funds. Working with the State, Secretary Levine,
Governor Jindal, they address the fact that immediately
afterwards about the only place for mental health service was
jail.
So we have put into place forensic assertive community
teams, adolescent community teams. I think there has been a
remarkable improvement in the coordination of care with the
Metropolitan Human Service District, which had some problems
prior to Katrina. It has a new executive director, a new
medical director, and is implementing, last week actually, a
very coordinated call center where if a patient shows up either
in a hospital or jail, something like that, then it is very,
very close to being coordinated, so that the case manager will
know that the next day and they can followup on that.
Also ways of following up when people don't get their
prescriptions filled where they should. So I think that they
are not represented here except for me, I am on the board. It
does represent a real success for the Primary Care Access and
Stabilization Grant. I am really happy to get a chance to help
you understand that has made a huge difference in a very
dysfunctional problem that we had.
Dr. DeSalvo. In answer to your question, we have integrated
at almost all of the sites mental health services into primary
care. One of the benefits of this program is we can have warm
handoffs, if I identify somebody who seems depressed or
anxious, I have services right onsite. I don't have to send
them home or refer them out. The flexibility in funding has
allowed that through this program.
Chairman Towns. The gentleman's time has expired. We have
four votes, so we will reconvene at 12:30. Of course, I would
like to ask unanimous consent that Representative Barbara Lee,
the Chairperson of the Congressional Black Caucus, be allowed
to sit and be allowed to ask questions. Without objection, so
ordered.
We will reconvene at 12:30. The vote is on now and we have
4 minutes left on the vote.
[Recess.]
Chairman Towns. The committee will reconvene.
The gentlewoman from California will be recognized for 5
minutes.
Ms. Watson. I want to thank our chairman for holding this
most necessary hearing. I want to commend all of our special
guests on the panel for coming today. I have been on special
delegations to New Orleans, and I was appalled at the promises
that were made and unkept. There were too many pieces of vacant
property, there were too many trailers with formaldehyde. I am
a victim of formaldehyde, too, and I know how you can suffer.
There were too few medical institutions. Catholic
Charities, I must give them credit, came in and they set up
temporary facilities to serve. But so many of our schools were
destroyed, so many of our universities were destroyed. My
grandmother was born in Louisiana, so I have a very personal,
personal affection for Louisiana. She was in a convent for 18
years. Obviously she came out. [Laughter.]
So I am very much a part of that particular State and the
French Quarter.
You are not to blame. We failed you, and we watched while
you were being failed. I was getting a call from the stadium
about how the buses were passing up the people and wouldn't
stop to pick them up. I had 14 relatives that we could not
find. We dispatched someone from my capitol, Sacramento, to go
to Baton Rouge. We finally saw one of the relatives hoisted up
and taken to a hospital. So I was very much a part of that.
So I say all that to say, I want to commend you for what
you have done, I want you to tell me now what we need to do in
health care reform, how we can plug up the holes. And this was
the biggest natural and national disaster we have ever had, and
the world viewed it. When the dikes broke and that water flowed
in like would flow into a bowl, we were all so tearful. So I
know what you went through. And I want you to tell us what we
need to do in health care reform that will plug up those holes,
and what we need to do in our system so never again will we
have to go through those levels.
I was not one to support Homeland Security to come and take
all the agencies. Because I thought FEMA should be separate and
apart so it could move on a dime. So in terms of health
delivery, what can we do, Dr. Townsend, Dr. Rowland, all of
you? Give us the input. Because we want to, before the end of
the year, come out with a bill that will cover all Americans
the right way, affordable, sustainable, accessible and with all
pre-existing conditions.
I just really appreciate Congressman Kennedy, who put a
particular emphasis on health care. I had a family in my home
whose son had a breakdown when he went back home and found out
they didn't have insurance, they lost everything. And so I know
the need for mental health services.
So let's just go down the line, starting with Dr. DeSalvo.
Why don't you give me the input on how we can make sure that
health delivery is sustainable and what we should do?
Dr. DeSalvo. Well, Congresswoman, thank you for remembering
and recognizing all that pain. We really do appreciate it.
Ms. Watson. I shared it.
Dr. DeSalvo. I just wanted to thank you. And what can we
do? We have done a lot with very little. And we are not asking
for much. I think what----
Ms. Watson. By the way, I am from California, the largest
State in the Union and the first State to be a majority of
minorities. So don't think that every Californian feels the way
I do, but you know how I feel. Go ahead.
Dr. DeSalvo. I think what we have built is really valuable.
It is an investment by the taxpayers, post-Katrina. It is
helping recover our city. It is building jobs. It is building
work force development, new opportunity for people. It is not
just about health care.
To continue it, the gap is somewhere in the neighborhood of
$30 million a year. It means that we can continue this until
there are other options, until finding special mechanisms to
pay for the uninsured aren't really needed because there are no
uninsured. And it would be really a shame to disassemble this
investment, which is really what we are facing in the fall.
So finding those funds could be really as straightforward
as allowing the Louisiana Recovery Authority [LRA] perhaps to
use some CDBG funds they have in a more urban renewal fashion
instead of just for housing. We don't want to not give people
housing. But if we think that we have access and we can give
them the fabric of community around their house, i.e., health
care, that would be helpful.
And there are some other opportunities, perhaps, with the
disproportionate share funds, to redirect it from using it only
for hospital-based care but also for community-based care.
Ms. Watson. Thank you.
Ms. Craft-Kerney. Thank you Congresswoman, and I appreciate
the feeling of just knowing that you care. So many people
showed that to us, and it just means so much.
I am not a policy person. I am a person who sees people on
the front lines. I am at ground zero in the Lower Ninth Ward.
But I can tell you what the impact should feel like. It should
feel like a person should be able to come to the clinic and not
worry about whether I can pay for it or not. It should feel
like, I can get the services that I need, whether it is primary
health care or specialty services. And I just want to say that
this has been a wonderful collaboration, because of the Primary
Care Access and Stabilization Grant, we have been able to work
together, something that I don't think we really did prior to
Katrina as much, but we were forced to. Necessity is the mother
of invention they say. And I am telling you, we definitely
forged a lot of friendships, invaluable friendships and
relationships, so that we could give the care to the people
that so desperately needed it.
And when we move forward, when the next catastrophe should
happen, we should definitely keep the people who have been on
the ground, who have built what we have today. They should be
the ones really to give you guidance. It shouldn't come from
the top down. It should come from the bottom up. Because we
have already shown that we have been very, very effective in
what we have been able to do. And with meager, meager
resources, we have given a lot of care. I have to commend all
of the people who are at this table who have a commitment and
who have been mission-driven to bring about these great results
that we have seen today. And that partnership with government
has been invaluable. We wouldn't have been able to do it
without you guys.
But the people who have been doing the work need to guide
the work. Thank you.
Dr. Erwin. Thank you very much, Congresswoman. I would like
to reinforce what has already been said. I think first and
foremost, we would like to maintain what we have accomplished
and maintain what we have. We all, I think most of us at this
table, realize that health insurance for everyone is a must.
When we are dealing with 72 percent uninsured, we see the
ravages of that.
But I would really like to make sure that we understand
that we, and other cities in California and everywhere else,
are having financial plights. That is very clear. What we would
like to encourage you to think about is that with the PCASG
money, you took a blank slate and you helped us build a health
care delivery system that has a good start. It doesn't take
massive amounts of money now to nudge it on to where we really
could become sustainable and we could become permanent and we
could grow. Because as you already heard, we are coordinating
mental health and primary care in ways that we had not been
able to do before.
So we really feel like that, we understand what it must
look like for us to be asking for money for just one particular
part of the country. But you have really helped, with the PCASG
money, you have really helped rebuild a health care system
better than it was before. Without a little bit of money now, I
think, relatively speaking, we will slip back. We will go back
to where there isn't the primary care, there are not the
community clinics, there are not the alternatives to the
emergency room care.
So we really do, first, I think, and foremost, want you to
understand the money you have spent has really made a
difference. You have really saved a lot of lives. We have
really built, starting with the Governor, Secretary Levine, we
have all worked together to build a better health care system.
I have been there for 30 years and this is the first time I
have seen the kind of collaboration and the input that we have
had both at the city and the State level and the community
clinics.
Ms. Watson. Doctor, can I just request of the Chair 3 more
minutes, so that we can finish up your panel?
Chairman Towns. Well, I would love to do that, but we sort
of----
Ms. Watson. A minute and a half?
Chairman Towns. A minute and a half.
Ms. Watson. Thank you. Mr. Griffin. You use the half, and
then we'll have the other two ladies split the minute.
Mr. Griffin. Thank you for the question. I think 100
percent access and 100 percent coverage should be, you asked
about reform, that is hopefully where everything is going. And
as it relates to the PCASG grant and what has been accomplished
in New Orleans, I do think there has been a tremendous
accomplishment of changing a system from hospital to primary
care. And when you talk about coverage, excuse me, when you
talk about access, nationally there will be a need for more
access to primary care. You could be looking at a model that
could be replicated nationally.
The vehicle for primary care development through the
Federal Government in the past has been through federally
qualified health centers. Most of the people sitting at these
table, only one of these entities qualifies as a federally
qualified health center. So this has expanded the opportunity
for, through this crisis, other entities to actually have more
dollars going to primary care and having more primary care
delivered in a community. We are changing the lifestyle and the
behavior of our population in New Orleans, which in the long
run will reduce costs to the health care system.
Dr. Townsend. I will echo a lot of what you have heard, and
that is, we have the beginnings of a network of care, which I
think is part of the answer for health care reform in the
future. And the other piece that is extremely important in
health care reform is going to be coverage. And we don't have
that piece yet. So I think what you are hearing is we would
like to see a bridge of funding, whether it is flexibility in
the Community Development Block Grant funds, or whether it is a
waiver for the disproportionate share hospital funding, to help
support these clinics that are an integral part of a network of
care.
Dr. Rowland. I would just echo those comments that the
coverage promised in the health care reform legislation passed
by the House would, of course, help many of these clinics to be
sustainable. But the implementation date there is 2013, maybe
2014, depending on the Senate action. And you really do need to
think about how to bridge us from where we are today to where
we would want to have these clinics be and the peoples'
coverage be in 2013. I think that involves both phasing in
better coverage for some of the low-income people, as well as
providing for support to these clinics during the bridge or
transition period, and recognizing that maybe one of the best
steps would be to try and develop a plan for how to turn the
clinics from freestanding clinics into those that can
participate in the federally qualified health center program,
which undoubtedly will have to remain a strong part of our
health reform efforts for medically under-served areas.
Chairman Towns. The gentlewoman's time has long expired.
Ms. Watson. Thank you, Mr. Chairman.
Chairman Towns. But I really felt that the information that
we were getting was just so important that we could not
interrupt. I think the timing of it means so much to us right
now here in Washington. So thank you very, very much.
I now yield 5 minutes to the gentleman from Ohio,
Congressman Kucinich.
Mr. Kucinich. Thank you, Mr. Chairman, for holding this
important hearing on the state of health care in the New
Orleans region.
One thing is clear, we must ensure that the clinics and
public hospitals in the area remain as strong as possible. The
need is unusually great there. As someone who believes that
health care is a human right, I think the people deserve help
from the Federal Government that will help them to fulfill that
need.
In the short term, we must shore up the Primary Care Access
and Stabilization Grant funds before they run out. And we must
build a new public hospital that is financially sustainable,
attracts world class providers, researchers, and students. If
such a hospital provides a little competition for more
profitable hospitals with a lower charity care patient mix,
then we should embrace that.
But this situation needs long-term fixes. A strong public
hospital and set of clinics in affected areas are part of that.
But New Orleans has for-profit hospitals, Mr. Chairman, around
the periphery of the city, who collectively take less than 15
percent of the charity care, leaving the rest to go to public
hospitals. It is called cherry-picking. It is not profitable to
provide health care to those who need it the most.
So the for-profit health care industry goes out of their
way to avoid it. The result is we are constantly fighting to
provide adequate publicly funded health care for the
disadvantaged. Now, if we are going to provide sustainable
health care for New Orleans, we need to make sure the hospitals
that are making big profits are pulling their weight. The
failure of profitable hospitals to provide adequate levels of
charity care is not simply a New Orleans problem. Indeed, in
Cleveland, Metro Hospital has a steadily growing patient mix of
charity care cases, which presents a growing financial burden
that strains their budget, the budget of the county and, of
course, the budget of patients and providers.
So I look forward to working with this committee to address
the role of private hospitals and clinics in bringing health
care to New Orleans and affected communities all over the
Nation. I have read the testimony of the witnesses. And I have
heard comments by my colleagues. I have heard one of my
colleagues refer to New Orleans as a ward of the Federal
Government. It is interesting, Mr. Chairman, this discussion
occurs 2 days after the President announced an escalation of a
war. We have money for war here, we don't have money for health
care. We have money for war and Wall Street, we don't have
money for health care.
You have a $100 million grant, as though you are supposed
to stretch that into the next year, you are running out of
money, to maintain a health infrastructure that was weak before
the storm hit. New Orleans was already in dire economic straits
before the storm hit. If there has been a hearing that puts in
bold relief more clearly about the distorted priorities of
America, I would like to know what it is, other than this one.
We are trying to keep alive a health infrastructure to assist
people, and we are getting ready to spend $160 billion next
year on a stupid war in Afghanistan. Billions.
I read the Kaiser report here which spells out the
statistics, the great health care problems that still exist,
the infant mortality that was high even before Katrina, the
number of AIDS cases, diabetes mortality, comparing Louisiana
to the rest of the United States. If we can't see that New
Orleans is still suffering, if we can't see that New Orleans
has a health care infrastructure that is not adequate to meet
the needs of people who are still recovering from this
hurricane, if New Orleans has to come here with a tin cup to
beg for money for clinics to--you have to fight FEMA to try to
get the money that you should have gotten, they are going to
arbitration, Mr. Chairman. The new hospital is going to cost
over $1 billion, and FEMA is nickel and diming New Orleans in
an arbitration as to whether they are going to get $100
million, $150 million, or the $492 million that New Orleans
wants.
This is a disgrace, really. It is good that you are here to
remind us. But really, our country is falling apart. And what
is happening in New Orleans is a signal condition of where
America's priorities are totally fouled up. You should not be
here begging, essentially, for recognition.
Thank you, Mr. Chairman, for holding this. But I will tell
you, the more I hear the drum beats for war and we are going to
go bomb poor people in Afghanistan and put a war into Pakistan,
we can't even take care of our own people here at home, how
disgraceful.
Thank you for being here. You have supporters in the
Congress who understand that the fate of America is going to be
linked to how we are able to take care of communities like New
Orleans that are still struggling to survive. And just know
that there are people right here who are standing right with
you on it. Thank you.
[The prepared statement of Hon. Dennis J. Kucinich
follows:]
[GRAPHIC] [TIFF OMITTED] T7790.072
Chairman Towns. Thank you very much. I would like to thank
the gentleman from Ohio for his statement.
Congressman Luetkemeyer from the State of Missouri.
Mr. Luetkemeyer. Thank you, Mr. Chairman.
Because of the specificity of the issue that we are dealing
with here today and its importance to Representative Cao, I
would, Mr. Chairman, yield my time to Mr. Cao. I feel he has
more direct impact and probably has more knowledge and a lot
more concerns about this issue than what I would have. But I
would certainly be supportive of him using all my time.
Thank you, Mr. Chairman.
Chairman Towns. The gentleman from Louisiana.
Mr. Cao. Thank you, Mr. Chairman.
I would like to thank Mr. Luetkemeyer for yielding me time.
First of all, I would like to thank Congressman Kucinich for
his passion and for his understanding of the situation in New
Orleans. I believe that he is clear on point with respect to
the needs of our people down there. We have been struggling for
4 years to rebuild the Lower Ninth Ward. New Orleans East,
right now there is a population of approximately 80,000 people
in New Orleans East and no hospitals to address the needs of
people there. So the needs are tremendous. And we will continue
to require Federal assistance to help us move forward in our
recovery. And in talking about recovery, I note that the new
Charity LSU VA system, or at least the hospitals that we are
planning to build will serve as an economic center for the
city. Dr. Townsend, if you don't mind, could you please
elaborate more on the plans for the VA LSU hospitals and where
are we with respect to that particular project?
Dr. Townsend. Certainly, Congressman, thank you.
We are in the process of doing the planning for the new
academic medical center. But I think it is important to note
that we recognize that the Charity model is not the model of
the future. It is not what we want to see going into health
care reform. It is not the best way to take care of patients.
So what we are building is a new academic medical center.
So LSU, in partnership with Tulane, can train our residents and
fellows and other health care professionals in that setting.
And as someone said, we can attract world class physicians,
researchers, do things there like you see in the Birminghams
and the Houstons, where many people in New Orleans go for care
today. We are exporting patients for health care, when we
should be able to provide that at home.
So what we are doing is, we are staying on track with the
planning process. We are waiting for a resolution from FEMA and
once we get that, we are going to move forward into this new
model. We are on track today to be in that new facility in the
beginning of 2014.
So at this point, without knowing the FEMA number, we are
still on track. We have not lost any time. But we have an
exciting project that we are hoping to move forward on.
Mr. Cao. Thank you, Dr. Townsend. Mr. Chairman, the issue
with FEMA is an issue that we have been battling for 4 years
now and Congressman Kucinich is absolutely right, the cherry
system is so integral for New Orleans. And FEMA is still nickel
and diming the city in order for us to get the system back
online.
I would really appreciate if we could have a hearing in
which we could invite FEMA to explain their position and to see
how we can try to overcome some of this impasse that we are
experiencing down there in the district. But I know that the
numbers between the State and the city, there is a difference
of around $300 million. Can you please tell the committee, how
important is it that we should receive the full $492 million to
rebuild the system?
Dr. Townsend. Someone mentioned the price tag for the
project. The hospital itself is about a $441 million
construction. But the entire complex, so it includes a clinic
building so that you can do outpatient, particularly specialty
services there on campus. So that $1.2 billion price tag, the
State has already committed $300 million to that project. And
the remainder of the $1.2 billion will have to be financed. And
a new entity is being created that will manage that new
academic medical center.
So they are going to be responsible for some sort of bond
issuance or some way to raise that money. So the difference
between raising $800 million or $400 million is significant. So
yes, we are hopeful that through the arbitration process that
is going on right now, that the State will get a favorable
declaration from FEMA and the number that the State has
submitted reimbursement for is $492.
Mr. Cao. Thank you very much. I see that my time has
expired.
Chairman Towns. Yes, thank you very much. Let me say that
we really tried to have this hearing in New Orleans. But the
schedule just got so messed up that we could not do that. And
of course, I am sure if we had had it in New Orleans that we
would have had others involved as well.
But the point is that we felt it was just too important not
to do it. And also, to commend you on the great work that you
have done, we wanted to do that as well. We think that you have
done an outstanding job in terms of and in spite of the
difficult conditions and circumstances.
Now I would like to yield to the gentlewoman from Ohio,
Congresswoman Kaptur.
Ms. Kaptur. Thank you, Mr. Chairman. I want to compliment
you for holding this important hearing, and for your
leadership. I know how much you care, as a health care expert
yourself, about what needs to be done in New Orleans and
Louisiana and many of the coastal areas that were so damaged by
Katrina.
I was fortunate to be able to travel to New Orleans and to
Mississippi with the Majority Whip, Mr. Clyburn, and with our
Speaker and others almost 2 years ago, now, I think it was.
That was very, very instructive. I guess I wanted to say to all
those who traveled here today from Louisiana, it is a gift of
the Christmas season that we get to meet angels who are on this
side of eternity and who are working and doing God's work. I
just want to compliment you for, you could be doing many other
things in your life and you have chosen to do this. The people
of my region, I know, admire it and view it as a very noble
effort. So let me compliment you for what you do and through my
remarks help to give you strength to continue to help those who
need it so much.
My question, I have a question and then a comment. Ms.
Bascetta, in your testimony you talk about an adequate
sustainability strategy to help these clinics in the future.
Hopefully, we will be able to get them additional funding. But
we would be interested in your suggestions on sustainability.
And Dr. Erwin, in your testimony you say if there is not
funding to bridge the gap after the public clinic, primary
clinic funding ends, many of your patients will revert
essentially to the same situation they found themselves in
immediately post-Katrina. I think it would be important for you
to state for the record what that would be.
Finally, before you answer, let me just say that when I was
down there as a member of the Agriculture Committee, along with
my other duties here, I was struck by the unmet opportunities
to use additional space that is available in New Orleans. I am
interested in having you submit for the record or comment here
today on how the added strength of food power and nutrition in
your region is being implemented. With all those open swaths of
land, with the possibility that primary health care clinics
could also become food stamp redemption sites for people who
grow food in the area, I can tell you in the community that I
represent, one of the eight poorest areas in the country now,
we get over $100 million a year of food stamps in the region. I
had a great epiphany a few years ago saying, ``hey, wait a
minute, we can turn these into economic development dollars if
we can get the people who live in these areas to actually
produce the food and turn them into food stamp redemption
sites.'' It is a no brainer. So we are about that task.
And I am just curious about these efforts perhaps being
made by your associates that could help your health clinics
also become nutrition clinics, and to deal with some of the
related health problems that you face. I am curious about your
progress on those. But in terms of my first question, which is
sustainability, Ms. Bascetta and Dr. Erwin, could you comment?
And then if anyone wants to say anything on agriculture, I
would be most grateful.
Ms. Bascetta. I would be happy to. We have heard that where
the rubber hits the road is the uninsurance problem. There
simply aren't revenues by definition from that population. And
it is a very large population in New Orleans, well above the
national average.
Ms. Kaptur. Could you pull your mic closer? I don't think I
heard you properly.
Ms. Bascetta. The uninsurance problem in New Orleans is
much more severe than the national average. That is where the
rubber hits the road in terms of sustainability. By definition,
that population doesn't provide any revenues to the providers.
They are uncompensated care. Historically, the only, the
funding streams that have provided reimbursement for those
people are either the DSH payments that we have heard about,
which are typically to institutions, to hospitals, unless there
is a way to redirect them through a waiver, and the HRSA health
centers also provide funding for people who are, for health
centers to take care of people who are uninsured.
Our view is that CMS and HRSA have already made a
significant investment in the area to try to do this model
demonstration of doing health care the right way, primary care
first, as the most important building block of the continuum.
It really would be a shame to have erosion in the progress that
has been made so far if the funds can't be made available to
shore up these clinics at this point.
And since the grant ends in September, we really don't have
10 months. It is pretty urgent now, in January, to make sure
that plans are in place. Because what happens if they are not,
providers begin to worry about their job security, they need to
know that there is going to be an infrastructure in place.
Patients begin to become anxious about where they are going to
get their care.
So it is important to expeditiously make a decision about
whether we are going to continue this investment that has made
this progress so far.
Ms. Kaptur. Thank you. Dr. Erwin.
Dr. Erwin. Yes, thank you very much. I would like to make a
comment about both the sustainability and the nutrition, if I
could. As I mentioned earlier, we have tried in a very
systematic way to deal with the issue of sustainability since
the grant came out. That is part of it. We have appreciated
that.
Our revenues, the patient care revenues that we generated
the first year, were around $238,000. This year it is going to
be right around $420,000. We have a pretty detailed process
where we try to help, we have representatives in the community
who work as our partners explaining to people that it is really
important for everybody to pay what they can to help us be
sustainable. And so we are dealing with the fact that almost
everybody pays at least $20, but the fact is, with a 72 percent
uninsured population, which is why we get out of bed every
morning, we are not going to try to get private pay until we
find some way for these patients to get their care met.
We are very hopeful about the expanded eligibility that
Secretary Levine can probably tell you about for Medicaid. But
that will be 2 years away. In our budget, we are pretty
conservatively working with our CPA. We really do think that by
year three, if we get a nudge and can continue on, by year
three we can be pretty well sustainable. We really do.
If I could just make a comment about the nutrition, too. We
have had, as part of our ``mental health program,'' an issue, a
program for community health and resilience, to try to
encourage healthy neighborhoods. We are a small clinic. We
don't kid ourselves about how broad our impact is. But we have
partnerships with one of the churches, the Sixth Baptist
Church. And we have a coffee shop that is part of our clinic,
that is run by the youth group at the church. There is 8 weeks
training to begin working there, after the first 8 weeks, when
they work in the coffee shop then they move to the kitchen,
where they make pralines. We are beginning to sell them on the
Internet. We have pepper sauce from a community garden that we
are selling.
So it is sort of a ``light a candle'' rather than ``curse
the darkness.'' But it has created a really positive mind set
with a lot of the youth, particularly. There are an awful lot
of kids who have nothing else to do. And so we feel like that
this type of thing is well worth our expenditure. We hope that
it is the kind of thing that we can continue to do.
Thank you very much.
Dr. DeSalvo. I think what Don is speaking to is this
concept that health is more than getting people to a doctor.
And it is an underpinning for all of us and what we do. We
think of our sites as centers, places where people can come not
only to become empowered, to get regular medical care, to learn
about their health, but almost all of us have programs that
reach out into the community and engage and empower them to
build economic opportunity, work force training, as Don is
describing, to help develop community gardens, to make it part
of the healthier foods in schools. The model here is really
going beyond just the idea of a clinic delivering medical care.
We feel an obligation to address the social determinants of
health as well.
Ms. Kaptur. Thank you, Mr. Chairman. Thank you all.
Chairman Towns. I now yield to the gentleman from Utah,
Congressman Chaffetz.
Mr. Chaffetz. Thank you, Mr. Chairman, and thank you all
for being here.
I would actually like to yield the time to Mr. Cao from
Louisiana.
Mr. Cao. I would like to thank the gentleman for yielding.
I would like to ask this question to either members of the
panel, maybe to Dr. Townsend, Dr. Erwin, Dr. DeSalvo. How does
the lack of a flagship hospital affect recruitment? And how
does this lack of recruitment affect the quality of care of the
people, especially for the poor people in New Orleans?
Dr. DeSalvo. I am happy to start. I think for the
university's part, the Charity Hospital system has been a
really important site for work force training for us for
generations. And it is the reason I came to New Orleans to
train at Charity. It is where I did my National Health Service
Corps payback. It is part of the fabric of how we develop new
physicians, nurses, etc. So there is the element of developing
the new work force to work in the community and to stay there
to take care of the population. That is important.
We are also realizing that if you are going to train folks
to work in community health centers or expect them to when they
complete, they need to have that opportunity. I think that is
really important, to shift that educational paradigm as well.
For our patients, especially for those patients of ours who
are uninsured, they are by necessity financially triaged. So
the State hospital system has been really critical in providing
specialty services and inpatient services for those folks. As
has been described, it is probably beginning to bulge at the
seams a little bit. So we need to think about how we improve
efficiencies of referrals and communication between the system
so we don't overwhelm them needlessly.
Mr. Cao. Dr. Townsend.
Dr. Townsend. I would say that actually, some of our
recruitment has been very good post-Katrina. But it is because
of the promise of a new academic medical center, a promise of
new labs for research. So if you are going to have those kinds
of, if those pieces of the infrastructure are going to be
present and are going to stay, we are going to need that new
medical center. We need a flagship hospital. As far as
recruitment for residents, I think it becomes a little more
difficult because we can't support the number of residents.
Today, we are supporting about 200 Tulane residents and fellows
at the hospital, because we just simply don't have the volume.
The 640 that were there before, they have to be in different
places. That education is not as attractive to residents and
fellows. So it makes it a little more difficult to recruit. Our
medical school recruitment is still going well.
I am happy to say, for the dean of the medical school at
LSU, his recruitment, like I said, with the promise of a new
academic medical center, our NIH funding now is actually higher
than it was before the storm. But that hospital is critical.
And Dr. DeSalvo is right, we need the clinics. Because that is
part of the training that is very important. But we have to
have that flagship hospital, we have to have those tertiary and
even quaternary care kinds of services that you simply can't
get in the outpatient setting.
Mr. Cao. Dr. Erwin.
Dr. Erwin. Thank you. It is particular pertinent to me,
because I have a son that is a medical student and we are
trying to recruit him to stay in town. And certainly, the
training that you have heard both of them describe that comes
with a flagship hospital that has academic excellence as well
as clinical care is critical. We also feel that one benefit
from recruitment has been the altruism of the country. We have
seen a lot of people come down who really want to help.
But it is very important, we feel, for people who are going
to work in community clinics, to train in community clinics.
They don't get that training in the hospital. It is a different
type of practice. So the residents, the students who come to
town who come out to our clinics, they make a difference for
us. They make a difference in the number of patients we can
see, they make a difference in the quality of services that we
offer. So that the higher quality that comes in, they don't
come for us. They are lured by the flagship hospital. We
benefit from it.
Mr. Cao. Now, there are areas in the second district, as
well as in Chairman Melancon's district, that lack hospital
care. And the statement from Mr. Issa saying that, what the
State is doing, in order to help those people there, my
question to you here is, I have spoken with the State and there
might be some issues with respect to how much the State can
contribute. Can LSU and Tulane, can you all come together in
order to address the hospital, maybe the acute care needs of
the people in Northeast and St. Bernard, and how can the
Federal Government assist you all in that endeavor?
Dr. Townsend. I think today, with the hospital that we
have, the public hospital that we have, for citizens in New
Orleans East who are uninsured, I think we are serving them
today. As far as being able to serve them in the area, I think
it is really important to have primary care, a bigger presence
there. And there are some conversations going on right now with
the city of New Orleans about the ability to use the medical
office building that was at the former Methodist Hospital to be
able to expand primary care services that would be a natural
link then into the inpatient care.
As far as inpatient services, without the hospital in New
Orleans East, obviously, I can't speak for Tulane, but I know
that there are always contractual relationships that can be
formed in order to have providers provide services at different
hospitals. Because we do that today in the New Orleans region
with other hospitals.
Chairman Towns. The gentleman from Utah's time has expired.
Mr. Cao. Thank you very much.
Chairman Towns. I now yield to the gentleman from
California who is the Chair of the Congressional Black Caucus,
who has been very involved and supportive of getting resources
into the Louisiana area, Congresswoman Barbara Lee.
Ms. Lee. Thank you very much, Mr. Chairman.
Let me thank you for your very consistent leadership on
this committee, and just as a Member of Congress and as a human
being with regard to your concern and commitment to ensure that
those living in New Orleans actually benefit from what our
Government has tried to do in the past. It is unfortunate that
this natural disaster was turned into a human disaster. Your
leadership and this committee's leadership makes us believe
that we will be able to do the right thing. But we have to do
it now. And I thank you again for inviting me to participate.
As Chair of the Congressional Black Caucus, let me just
welcome all of you, greet you and just say, thank you for being
here. Most members of the CBC have been to New Orleans many,
many, many times. And each time we go, we want to come back. We
believe we are not doing enough yet and we have to do more. So
this is an important step in the right direction.
I hope, Mr. Chairman, that in the future, this committee
could lead a delegation to visit New Orleans once again, but
look specifically at the primary care clinics and community
care clinics. If that request hasn't been made formally, I
request that, because I think it is time we come back. And
especially now during this health care reform debate, and part
of what we have been insisting on in at least in the House bill
was an expansion of community clinics. So some of us would like
to see how that would work, post-Katrina. Because we think if
it can work, if it is working in New Orleans, it can work
anywhere because of all of the issues, the tough issue that you
are dealing with.
Let me ask you, a couple of things about medical records.
On a couple of occasions, I visited and went to the hospitals
and talked to some of the personnel and was concerned, they
were concerned, like many of us, and I know you are, about the
medical records and how you retrieve medical information from
people who are coming back. Do you have medical records in
terms of the computerization and the technology necessary for
retaining, now, medical records, or how did all of that happen
with regard to those who lost their homes and had to leave and
are now coming back? How do you recapture medical histories?
Mr. Griffin. I would like to respond to that. We have, I
think since Katrina, developed a fairly robust system with
electronic medical records. At Daughters of Charity Services of
New Orleans, we have a paperless system for the most part. It
is backed up out of town so that there is no jeopardy of losing
the information. And our providers are able to access the
records remotely. So that has been a, there are multiple
vendors that entities are using. But it has been, of course,
helped by this grant because of the operational assistance and
infrastructure that this grant has provided. So that has been a
true evolution and something that has worked very well.
I would just like to thank you for all of your, from the
Congressional Black Caucus' Chair, for all the work you have
done and all you all have done to look at New Orleans and
assist New Orleans. And also I would like to express your
sentiment with the chairman. Mardi Gras is coming up, so you
all can have a visit or come down in 2 months if you like for
your site visit. [Laughter.]
Ms. Lee. Thank you very much. And thank you for that
invitation.
Dr. DeSalvo. I just want to add to what Mike's saying, that
the opportunity from the loss of our paper records was to
rebuild it better. We have done that. We felt as a group of
community providers that we wanted to move toward a paperless
system. We think it has better safety parameters. It is more
accessible for providers, if it is after-hours calls that we
take on patients, we have the information at our fingertips to
help make care decisions, to let them decide whether the
emergency room is the right place or the clinic.
It has also really helped to advance our programs in
quality and quality improvement and helped us to share
information to think about how we are going to treat chronic
disease like diabetes better.
Ms. Lee. But I have to ask you though, for those who lost
everything, and I say this as the daughter of an 85-year-old
mother who walks around with a briefcase full of medical notes
and records, because where she lives they still aren't
computerized, and there is no technology. So to remember, for a
person who left during the storm, came back, lost everything,
how do you reconstruct a record? I can't remember everything
that, for instance, every medication that my mother takes or
every diagnosis. How did you do that and how do people put all
that together again?
Dr. DeSalvo. It is a lesson learned from this tragedy,
really, because we didn't have a lot of that information. So we
did not want to go back to that situation, if it were to ever
happen again. And we think, for disaster and every day, it
makes sense to have the information available, not just to
providers, by the way. The step we are not at yet is the portal
for patients. Because really, they own that information and
should be able to see it any time that they need to have access
to it.
But what it took in the beginning was, honestly, we had
records in the Charity system. That system, some of the
dictator boards and labs were available, some of the hospitals
had their inpatient electronic systems. So we pieced it
together, painstakingly with folks. And it does take quite a
long time when you are getting folks re-entry, over an hour or
more, just to find out what happened to them in their lives and
make sure it is not lost again.
Ms. Lee. Yes, and what medications, for example,
understanding the health disparities in the African American
community, diabetes, hypertension, lung cancer, breast cancer.
How do you reconstruct the medications?
Dr. Townsend. One of the advantages that we had was that
the collaboration through an HCAP grant, there was the PATH
partners that many of these folks belong to, including us, we
had developed a retrieval system for electronic information.
And so that piece of information, that history was available
electronically, even after the storm. In addition to that, the
pharmacies across the Nation, if you use a retail pharmacy, you
could retrieve that information of filled prescriptions. And
then for our patients, most of them don't have a pharmacy
benefit. So we access patient assistance programs and they get
free medications. But there is an electronic system within the
safety net that keeps track of what medications they have
received.
That is important information. We were able to reconstitute
that information very quickly.
Ms. Lee. That is great. Let me ask you one more question,
Mr. Chairman, to this panel, as it relates to HIV and AIDS. How
are you faring, and how are the rates in New Orleans as it
relates to HIV and AIDS, and are people able--I remember
earlier, right after the storm, accessing medications and
getting people back on their meds at the right time and what
have you was a difficult task. Are the rates now leveled off in
New Orleans, are they going up, going down? Do we need to look
at New Orleans and see what we need to do and do it better? How
are things going?
Dr. Townsend. HIV care in New Orleans, the public
hospitals, clinics, it is called the HOC clinic, the HIV
Outpatient Clinic, that clinic has been reconstituted. People
are back in care. They are able to receive medicines. We have
always had a really high diagnosis rate in New Orleans. I
actually am not sure what that is today. My guess is that
perhaps because the population is down, the rates may not be as
high as they were. Because we have diagnosed so many of those
people. But there are still people who are not in care. And we
are still trying to get those people to the appropriate level
of care. This is one place where we have made such great
strides that you can really manage that disease on an
outpatient basis.
Ms. Lee. Are you able to do testing initiatives, testing
drives?
Dr. DeSalvo. We are, and I think Diane can tell--I believe
we have the second highest rate in the Nation of HIV after D.C.
It is a major problem. There are programs in place for
screening, education, identification, triaging people to care.
One of the recipients of PCASG is the NO/AIDS Task Force, which
has benefited and been able to grow its programs. So it is on
the front of our minds. We know it is a major problem for the
population and quite frankly, the community is very conscious
of it. Of the things that we get requested as a health center
to go do screenings on, it is HIV more than diabetes now.
Chairman Towns. Thank you very much. Let me thank the panel
for being here. We really appreciate your coming and sharing
with us, because we see it as being very, very important. And
of course, we want you to know that you do have a lot of
support on this side. We just hope to be able to move some of
these things a lot quicker. But again, your coming here has
been extremely beneficial.
Also I would like to just say that I also have a letter
that is addressed to both Congressman Issa and myself from Mr.
Melancon regarding this hearing. As you know, he represents
several of the most affected regions recovering from Hurricane
Katrina, including St. Bernard Parish, of course, and
Plaquemines Parish as well, which are just east of the city and
still recovering. He has been a leader on recovery,
particularly in the areas of restoring and building the
region's health care infrastructure. I would like to put this
letter in the record.
[The information referred to follows:]
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Chairman Towns. Let me again thank you so much. Now we move
to our second panel. I apologize for the delay because of
votes. But in the meantime, we have to vote around here. If
not, they talk about you. [Laughter.]
So we will now move to our second panel.
Will all the witnesses come forward, please.
Let me just indicate before we start, we swear all of our
witnesses in. What we will do is we will allow you to start,
but we will have to have another break to go and vote. I really
apologize. They make an issue of it if you don't vote around
here. So please stand and raise your right hands.
[Witnesses sworn.]
Chairman Towns. Let the record reflect that the witnesses
answered in the affirmative.
Let us begin with you, Dr. Brand. Thank you so much for
being here. I really appreciate your being here all day, too.
Thank you so much.
STATEMENTS OF MARCIA K. BRAND, PH.D., DEPUTY ADMINISTRATOR,
HEALTH RESOURCES AND SERVICES ADMINISTRATION, U.S. DEPARTMENT
OF HEALTH AND HUMAN SERVICES; ALAN LEVINE, SECRETARY, LOUISIANA
DEPARTMENT OF HEALTH AND HOSPITALS; JOIA CREAR-PERRY, M.D.,
FACOG, DIRECTOR OF CLINICAL SERVICES, HEALTH DEPARTMENT, CITY
OF NEW ORLEANS; AND CLAYTON WILLIAMS, MPH, DIRECTOR, LOUISIANA
PUBLIC HEALTH INSTITUTE
STATEMENT OF MARCIA K. BRAND
Ms. Brand. Mr. Chairman, members of the committee, thank
you for the opportunity to testify today on behalf of the
Secretary of the Department of Health and Human Services [HHS]
and the Administrator of the Health Resources and Services
Administration [HRSA]. We appreciate your interest and support
of primary care in New Orleans and welcome the opportunity to
work with you to strengthen HHS and HRSA programs in the
region.
I appreciate the remarks of the previous panel and I
applaud their fine efforts to provide access to care for the
people of New Orleans.
HRSA also helps the most vulnerable Americans receive
quality primary care without regard to their ability to pay.
HRSA works to expand health care for millions of Americans, the
uninsured, mothers and their children, those living with HIV
and AIDS, and residents of rural areas. HRSA recognizes that
people need access to primary health care and through its
programs and activities, it seeks to meet those needs.
My testimony will briefly describe the Centers for Medicare
and Medicaid Services [CMS] Primary Care Access and
Stabilization Grant and ways that HRSA is working with its
partners to provide access to primary care services in
Louisiana. In July 2007, CMS awarded Louisiana the Primary Care
Access and Stabilization Grant, a 3-year grant of $100 million
to assist public and not-for-profit clinics in the greater New
Orleans area to expand access to primary care, including
primary mental health care, to all residents, low-income and
uninsured residents. The grant was designed to support the
long-term sustainability of primary care in New Orleans. The
grant required sustainability plans within the grant
application and tapered funds over the life of the 3-year
grant. The Louisiana Department of Health and Hospitals made
provisions with the Louisiana Public Health Institute to help
the State administer and oversee this grant's day-to-day
operations.
As we have heard from the previous panel, the organizations
receiving PCASG operates 91 primary care and behavioral health
clinic sites across the region, including fixed and mobile
facilities. As of September 2009, these clinics have served
approximately 252,000 patients. The Department is pleased with
the improvements in primary care access that has resulted form
this grant. HHS looks forward to continuing our close
partnership with the State and local health care organizations
to meet the primary care needs of residents in the Gulf Coast.
HRSA's efforts to support primary care in post-Katrina New
Orleans includes support for health centers, the primary care
work force and infrastructure. Health centers are community-
based and consumer-driven organizations that serve populations
with limited access to health care. These include low-income
populations, the uninsured, those with limited English
proficiency, individuals and families experiencing
homelessness, and those living in public housing. These centers
are designed to provide accessible, dignified, health services
to low-income families.
In 2004, prior to Hurricane Katrina, HRSA funded two health
center grantees that supported 10 sites in New Orleans, serving
17,500 people. Since 2006, HRSA has funded seven additional
applications. HRSA provides grant support to five health center
grantees in the greater New Orleans area. This includes four
existing health center grantees that received $7.1 million in
2009 to operate 18 sites and service 34,000 people.
The fifth health center is a new grantee that received
funding under the Recovery Act. New Orleans has additionally
benefited from Recovery Act funding and has received 13 awards
that support new health center access points, increased demand
for services and capital improvement awards. The Recovery Act
funding will allow these primary care providers to see an
additional 35,000 patients at more than 20 clinics across the
area over a 2-year period. Two of the health centers are using
these funds to provide additional mental and behavioral health
services, which we know from our discussions today are critical
to this region.
In addition to providing direct patient care, HRSA
strengthens primary care by placing health care providers in
communities where they are needed most. The National Health
Service Corps, through scholarship and loan repayment programs,
helps health professional shortage areas in the United States
obtain primary care. And Dr. DeSalvo, who was on the previous
panel, is an excellent example of the National Health Service
Corps loan repayment program.
In addition to supporting a National Health Service Corps,
we directly support health professions programs that provide
infrastructure for training and education. This includes the
Southwest Area Health Education Grant.
We also provide resources to address particular patient
population challenges, including women and children. And as of
this summer, we had another grant that would support care for
people living with HIV and AIDS. HRSA provides Ryan White care
funds to the New Orleans AIDS task force. And they provide
comprehensive HIV care for about 800 people living with HIV and
AIDS.
We are extremely proud of our programs and look forward to
continuing to work with you, Mr. Chairman, and members of the
committee, to provide quality primary care for all. HHS has
invested a great deal of time and resources in assisting the
recovery of New Orleans, and there is much more work to be
done. We are looking forward to collaborating with you in that
effort.
[The prepared statement of Ms. Brand follows:]
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Chairman Towns. Thank you very much, Dr. Brand.
Just before we start with Mr. Levine, we are going to break
until 2:15. We hate to do this, but we have to make these
votes. And then we will start again. And of course, hope that
we won't have any more votes until we finish. Thank you, and we
hope you understand. So we will actually recess until 2:15.
[Recess.]
Chairman Towns. The committee will reconvene.
Mr. Levine, you may begin.
STATEMENT OF ALAN LEVINE
Mr. Levine. Thank you, Mr. Chairman. It is an honor to be
here today.
I had prepared some comments, I am going to depart a little
from my prepared comments and sort of get to the crux of what
some of our financial challenges are going forward. You have
heard good stories this morning about the good things that were
done as a result of this grant. There were other grants as
well. And Congress and the executive branch have done a lot for
the State of Louisiana and New Orleans. For that, we are
grateful.
We are also grateful for the selection of Craig Fugate to
be the Administrator of FEMA. I worked with him during the
eight hurricanes that Florida faced during 2004 and 2005, and I
don't know a more capable person in the country to lead FEMA.
I just want to get to some of the real financing challenges
that we have that really trump all of this. Because all of this
will become very difficult for us to sustain, if we can't solve
these specific issues. First, our State faces the largest
reduction in Federal match in Medicaid in the history of the
Medicaid program. January 2011, our Federal match will decrease
by 18 percentage points from an 81 percent match under the
stimulus to 63 percent. That is an annualized loss of $900
million per year that Louisiana will either have to, will have
to reduce from the expenditures in the program. That is one-
sixth of our Medicaid program.
On top of that, we face a reduction in our DSH program. You
have heard a lot about the low eligibility, the 12 percent
eligibility for adults in Louisiana. Part of the reason for
that is we have historically used this public hospital system
to provide access for people that were low income. You heard
that nearly 95 percent of our children have insurance coverage
and we have a very low eligibility for adults. That is true,
because we have this public system.
However, the funding for that public system is in jeopardy
right now because beginning in July, we face what we estimate
will be up to a $150 million reduction in our DSH program, a 20
percent reduction that begins July 1st. So those two issues
combined are more than a $1 billion reduction to our safety net
programs this coming year. We also are facing obviously the
loss in the Primary Care Access and Stabilization Grant
funding.
I just want to tell you a story. My first week on the job,
there was a young police officer named Nikola Cotton who was
murdered on the job. She was murdered by somebody who had been
treated in our institutions, in our mental health institutions
in New Orleans and had just been released from a mental health
institution. We found that the mental health system in New
Orleans and throughout the State of Louisiana has been
neglected for 20 years.
So the Governor and I set out, along with the legislature,
and some of them are here today, to establish some major
reforms in our mental health system. We passed several laws,
one of them that we refer to as Nikola's law, that allows for
involuntary outpatient treatment for people who don't take the
medications when they are determined to be at harm or risk to
themselves or others. We increased funding for mental health by
$89 million. We implemented forensic assertive community teams,
assertive community teams, multi-systemic therapy, functional
therapy, services that had never been offered in New Orleans
before that today are being offered.
And because we are doing it and because we have tried to
move the standard from institutional care to a community-based
model, we are serving three times the number of people that
have mental health needs.
I want to say, there was a question earlier about what is
Louisiana doing. Let me tell you some of the things that we are
doing. First of all, I mentioned we have increased our funding
for mental health by $89 million last year, even facing
economic challenges that we are facing. The Department of
Health and Human Services just put out a press release a couple
of weeks ago, or put out a statement a couple of weeks ago,
saying that Louisiana is one of the most efficiently operated
Medicaid programs, and it is the model for how to retain
coverage for children.
We went from 44th in the Nation for child immunizations to
just a month ago CDC announcing that we are now second in the
Nation in child immunizations, pushing our overall health care
rankings to 47th in the Nation. Still very low, but the highest
we have ever had since the rankings have been done.
So there is forward progress being made. But if we do not
solve these challenges, these financial challenges, if the FMAP
problem does not get resolved, the consequences will be
extremely devastating for our State and many of the gains that
you have seen, particularly the investments that have been made
by the Federal Government will be, we think, in peril. To be
clear, the reason that the Federal match is dropping in
Medicaid is because of the very things you have done to help
us. It is an ironic twist in the formula. The Medicaid matching
formula was never designed for States that had major disasters.
So what happens is, tremendous investments are made, billions
of dollars of investment are made in our State, economic
activity occurs, we have a temporary increase in our per capita
income. Our per capita income went up 42 percent from 2005 to
2007. But yet we still have the second highest rate of poverty
and our Medicaid enrollment is the highest it has ever been.
And yet, 3 years later, because of the Federal formula in
law, our match in Medicaid drops as a direct correlation to the
increase in the per capita income resulting from the recovery.
Mr. Chairman, I know my time is up. I will say that this is
something that only Congress can resolve. We literally are
asking for Congress to take a good, hard look at this to help
us with this financing challenge that no State in the history
of our Union has faced in the Medicaid program's history.
[The prepared statement of Mr. Levine follows:]
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Chairman Towns. Thank you very much, Mr. Levine.
Dr. Crear-Perry.
STATEMENT OF JOIA CREAR-PERRY
Dr. Perry. Hello, thank you for having me. I am Dr. Joia
Crear-Perry. I am the director of clinical services of the city
of New Orleans Health Department and I am an OB-GYN. I would
like to thank the House Committee on Oversight and Government
Reform for giving the city of New Orleans an opportunity to
speak today and for providing us funding for primary care
access and stabilization.
This vital funding helps support the city to re-establish a
health system of care, along with providing critically needed
medical and mental health services to the greater New Orleans
community and areas post-Hurricane Katrina.
The causes for our historical social health disparities as
a State, and more specifically in New Orleans, are complex and
far-reaching and not easily counteracted. When Katrina made
landfall, 28 percent of New Orleans' citizens lived in poverty,
25 percent had never finished high school, 50 percent lived in
a single parent home and 25 percent had no health insurance.
Hurricane Katrina has only exacerbated what was already a
fragile health infrastructure and medical service delivery
system. The current lack of access to both primary medical care
and mental health services for such a large portion of our
parish is perhaps the strongest correlation to our repeatedly
poor health outcomes.
The goal of the New Orleans Health Department is to provide
direct medical care and services and help to build a
sustainable and long-term infrastructure along with the
opportunity for collaboration and coordination in creating an
equitable and accessible health care system for all residents.
Therefore, I would like to focus on five things: the lack of
access to primary medical care services by our citizens most in
need; the professional medical and mental health provider
shortages; a profound lack of mental health services; health
disparities; and the need for continued support to finish the
rebuilding of the city's health infrastructure.
Today, with the population of New Orleans having reached an
estimated 350,000 people, close to 75 percent of its pre-
Katrina numbers, the services offered by the New Orleans Health
Department are much less. The city operates only three primary
care clinics: one homeless clinic, one fixed dental site, and
two mobile dental sites. The geographic coverage is limited.
One of the primary care clinics is located on the west bank,
and we have the map up there. One is located in Central City
and one is in New Orleans East, across the large Industrial
Canal. If you look to the right of the map, where there only a
couple little dots in the far right corner, that is New Orleans
East, where our clinic is.
There has been a significant decrease in the number of
medical, mental health, and dental providers seen in Orleans
Parish. According to a 2007 Blue Cross/Blue Shield report, only
28 percent of their original medical professionals returned to
practice in Orleans Parish. Last year, the Louisiana Department
of Health and Hospitals reported that less than 25 percent of
those providers accepted Medicaid patients.
There has never been an adequate mental health
infrastructure in New Orleans. And today, the need for care and
treatment has only increased exponentially since Katrina made
landfall. During the last 4 years, the availability of
psychiatric beds has been dramatically reduced, combined with a
large number of mental health care providers never returning,
which has left the citizens most in need with the most
obstacles in receiving care, needed care and treatment. And
beyond that, being able to meet the mental health needs of our
citizens, it has created a cross-cutting effect on families,
communities, work sites, and the broader health care delivery
system--from the hospital emergency rooms to the primary care
physicians to the local jail facilities--which today houses the
most psychiatric beds in the parish.
Just as behaviors and lifestyle choices are the causes of
most chronic and infectious diseases, access to primary,
preventive, and treatment care is what improves health outcomes
and decreases disparities gaps. What research has shown is that
health disparities in Louisiana are often found in populations
which are poor, minority, high school dropouts, low incomes,
uninsured, and lack transportation.
The New Orleans Health Department identified an extremely
high need in under-served and under-staffed sites in New
Orleans Parish and responded by establishing a clinic site with
PCASG funding. As you can see on the map, it was New Orleans
East. New Orleans East represented approximately 35 percent of
total parish land area and 15 percent of overall population.
Yet 4 years later, there is still no hospital. So I just wanted
to put up my little Methodist picture. Can't have a New Orleans
conversation without talking about Methodist Hospital.
Yet separated by the large Industrial Canal, New Orleans
East is considered a suburb of the city, with the fastest-
growing part of the parish in terms of population, business and
industry, with a strong, increasing middle-upper class Black
population and Vietnamese population. Like all of New Orleans,
but particularly New Orleans East, data has shown a significant
population shift. Each month that the New Orleans clinic has
been open, we have seen a 15 percent increase in patient
volume. We currently offer gynecologic, pediatric, adult
primary care services, WIC and Healthy Start. We have
collaborations with LSU and Tulane Schools of Medicine for
specialty care, diagnostic procedures, and inpatient
management. Sixty-five percent of our patients are uninsured.
Our typical patient is a working mother who comes in for WIC
services, brings in her children for pediatric services,
participates in Healthy Start parenting classes, gets her PAP
smear and birth control, and has her brother to come in for a
blood pressure check. She can get all of this done at this one
site in New Orleans East.
For a growing population that is geographically isolated,
the PCASG funding has allowed us to provide convenient,
compassionate services, because even 4 years later, there is
still very limited care in the area.
Since Katrina, there has also been a severe shortage of
dental services. The PCASG funding has allowed us to fill in
the gap by staffing two mobile dental units. One goes to the
senior centers, and one goes to the school-based health units.
On these units we provided dental exams, prophys, deep
scalings, amalgam, bonding, removable partial dentures,
complete dentures, crowns, and bridges. We have an oral surgeon
who can help with more difficult cases. We have begun oral
health education programs with the schools as well. So you can
see one of our vans we are very excited about.
We are hopeful that the availability of services plus the
student education will span out to beyond the schools and the
senior centers in the future. Right now, it is filling a
significant need.
So in closing, I know I am over, below are a couple of
recommendations from the city of New Orleans. No. 1, to
increase Medicaid eligibility, to increase the number of
individuals who qualify for coverage and are insured. Two, use
flexibility within the Section 1115 waiver for Medicaid for
expansion to support the PCASG funding; expand the number of
federally Qualified Health centers in the region; and to
alleviate the disparities in mental health reimbursement. That
is it.
[The prepared statement of Dr. Crear-Perry follows:]
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Chairman Towns. Thank you very much.
Mr. Williams.
STATEMENT OF CLAYTON WILLIAMS
Mr. Williams. Mr. Chairman, thank you and members of the
committee, thank you for the opportunity to address this
important topic today.
I am employed by the Louisiana Public Health Institute,a
non-profit organization that works State-wide to improve health
through public-private partnering. LPHI was chosen as the
State's local partner in administering the Primary Care Access
and Stabilization Grant. I serve as the director of that
program.
Today my testimony will, in my 5 minutes, hopefully
summarize how the grant has been used over the past year, 2
years, toward the grant goals, and discuss the challenges we
face in maintaining the gains we have achieved. The
catastrophic flooding throughout the New Orleans region
following Hurricane Katrina wiped out the health care safety
net, as you have heard about today. There is a map showing the
relative flood depths that you could look at in relation to the
location of the clinics, which is overlapping.
Also, as you have heard today, the clinic representatives
here today were among those who spent the first couple of years
after Katrina cobbling together resources and trying to get the
growing health care needs met in the region. Then in July 2007,
we received the $100 million Primary Care Access and
Stabilization Grant from HHS to stabilize and expand the
clinics that were on the brink of failure at that time. We want
to thank you and HHS very much for making that possible and
making it possible under terms that allowed for the use of
those funds in a flexible way, so that we could be effective
toward the goals of the grant.
We strive for a health care system with a public-private
network of primary care clinics as its foundation to facilitate
access to the right care delivered in the right place at the
right time. And four fundamental goals have guided our efforts
to use this grant to advance toward this vision. No. 1,
increase access to care on a population basis. No. 2, deliver
high quality, evidence-based health care. No. 3, create an
organized system of care. And No. 4, develop sustainable
business entities: access, systemness and sustainability have
been our mantra.
Twenty-five public and non-profit organizations in the New
Orleans region were eligible to participate in the grant
program. The first award of $16.7 million was distributed to
the organizations within 2 months after the issuance of the
notice of grant award. Supplemental awards have been made every
6 months since then to all 25 entities. And so far, $80,275,000
has been distributed.
The remaining grant funds will be distributed in December
of this year, and the grant funds will be substantially
exhausted by September 30th of next year. However, we expect a
no-cost extension will be approved by CMS shortly to help the
grantees stretch these dollars as far as possible. About 80
percent of the funds have been spent on personnel and contracts
for the provision of direct patient care services and the
remainder on equipment and supplies, facility renovations, and
other expenses that support care delivery.
Now, I will summarize the status and progress made toward
our priority goal, to increase access to care on a population
basis. The outstanding performance of the 25 participating
organizations in this priority goal area has led to an increase
in the number of service delivery sites in the region from 67
per-grant to 93 today. There is a map you have seen that shows
the distribution of all those sites across the region. In
addition, they have increased the size of the delivery system
by almost 50 percent in 2 years in terms of patients served.
You can look at the next exhibit, which is a graph that shows
the increase in patient volume by a 6-month period since the
beginning of the grant. It is a dramatic, dramatic growth in a
system in such a short period of time.
In the past year, they have provided primary and mental
health care services to nearly 175,000 individuals and to a
total of 250,000 since the grant began. In the past year, 42
percent were uninsured, representing about half of the
uninsured in the region, and 25 percent had Medicaid. More
importantly, over 40 percent of the conditions cared for in the
primary care clinics are conditions that would likely require
expensive emergency room care if not effectively managed in the
outpatient setting.
Now on goal No. 2, which is to deliver high quality
evidence-based health care, as a condition of receiving grant
funds, all participating clinics met minimum quality
improvement benchmarks, such as providing same day appointments
for urgent care. In addition, $3.8 million was set aside for a
voluntary quality improvement incentive program in partnership
with the National Committee on Quality Assurance [NCQA]. This
incentive program rewards clinics that achieve standards set by
NCQA in their patient-centered medical home framework.
Significantly, 40 of the clinics received NCQA recognition
through the incentive program. This is the highest
concentration of such recognized clinics anywhere in the
country. And just 2 days ago, we heard that this impressive
cross-sector quality improvement will receive a national award
from NCQA in March of next year.
I have 1 more minute here. I am going to skip down to goal
No. 4, sustainability, which I think is the focus of the
hearing here. Substantial improvements in billing practices
among the participating organizations have been achieved. For
example, 82 percent of the primary care organizations are now
billing Medicaid, Medicare, and/or private insurance.
Despite the progress that has been made in this goal area,
we estimate the participating provider organizations would face
a $30 million annual operating deficit if they were to maintain
their current capacity without the help of this grant or some
other such source. The projected deficit stems from their
mission to serve people who are not covered by any insurance
and hence from whom the clinics receive little or no revenue.
Over half the participating organizations depend on grant funds
for more than 50 percent of their operating expenses. And
several rely on grant funds for more than 75 percent of their
operating expenses.
Organizations caring for the highest portions of uninsured
individuals are most at risk, and some of the highest volume
and highest quality clinics that you have heard from today have
patient populations that include upwards of 70 percent
uninsured individuals. This program was envisioned as a bridge
to a more favorable policy environment. However, it is clear
that those conditions are still years away. Unless we work
together now to devise and implement solutions to span the gap,
the progress that has been made will quickly erode, and the
health system recovery in the New Orleans area will take a
giant step backward, resulting in an estimated 30 to 40 percent
reduction in services overall among these organizations.
Most organizations will be forced to cut back severely.
Several will likely fail altogether. Many people who currently
rely on these clinics will go without care or end up in the
emergency room. Meanwhile, if and when relief comes down the
road in the form of coverage expansion, the expensive exercise
of expanding the health care delivery system to handle the new
demand will have to be repeated. Wouldn't it be more effective
and efficient overall to keep this network intact than to let
that happen?
The desirable result of this hearing would be that all
parties involved will redouble their efforts to immediately
identify and implement a set of solutions to address these
threats. These could include allocation of existing unobligated
community block grant recovery funds for this purpose, granting
permission for the State to use Medicaid disproportionate share
funds for outpatient primary care and physician services, and
exportation of additional sustainable options for funding.
It has been an honor today to participate in the hearing,
and thank you for your continued support of our efforts to
rebuild a healthier, greater New Orleans. I would welcome your
questions.
[The prepared statement of Mr. Williams follows:]
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Chairman Towns. Thank you very much. Let me thank all of
you for your testimony.
Let me begin with you, Dr. Crear-Perry. I am interested in
that van. How does that work? Do you go to the same area once a
week, twice a week? How does that work?
Dr. Crear-Perry. We actually have an MOU with the school-
based health clinics. The one that you saw with the children on
the van, that one goes to the schools. They make a schedule, so
the school nurses at the schools will find out which kids need
dental services. They send home a packet with all the kids and
their parents fill it out. Then they make a schedule and they
let us know that if we are going to have, say, 10 kids the next
day, and we usually have a schedule for the week. We right now
are rotating between two different schools. We go to one school
1 week and then one school the next week.
Each week, we get requests from other schools. Everybody
wants it, because there is such a need for dental services in
the city. So some of the hardest part is just getting through
the bureaucracy to make sure that we can get it there and get
the services to them. But the kids really do enjoy being able
to get the services. Because a lot of times we have kids who
haven't been to the dentist since the storm. And we have been
able to take care of them on the dental units.
Now, for the senior centers, it goes to four different
senior centers in the city. It also has a schedule that it
changes every day from one senior center to the other. So the
senior centers are more consistent. They know their schedule.
They come in, and so it is a lot easier to get the senior on
the dental van than it is sometimes to get the children.
Chairman Towns. Dr. Brand, and first of all, I want to
thank you for staying all day and listening to the testimony
earlier and then coming and testifying later. I want you to
know that when I became Subcommittee Chair back some years ago,
I was going to change the procedure, because I wanted agency
people to hear in terms of what was being said. Because we
always had the agency people first, and then after that we
would bring others in. After the agency people would testify,
everybody would get up and walk out. And then when the people
that had the problems, when they testified, nobody from the
agency was around to hear it.
So I was the one who said, from now on, we have the people
talk first and then have the agencies come in afterwards. But I
want you to know that your being here all day today has made me
sort of rethink this thing, because you have been here and you
have listened to the testimony. I want to ask you, you have
heard what was said. Do you think it is possible that maybe the
agency would think about, let's look at sort of establishing or
sort of group a task force, I don't like the word task force,
but a group to work together to see in terms of how we might be
able to move some of these efforts along? I know you might not
be able to make the decision sitting at the table today. But
can you take this back to request that we would like to
establish a committee to explore ways to continue restoring
health care services to the post-Katrina region?
I think there is still a lot that needs to be done. I know
you can't right away say. But the point is, if you could take
that back and let us know if there is any real interest in
this. There are many Members of Congress, along with the
representatives from the area, that would like to see what more
we might be able to do. Sometimes it is not money, it is just
getting things coordinated. I want to get your views on it and
recognize that it is not something you can bang the table and
say you will do. But will you take that back and think about
it?
Ms. Brand. Yes, sir. And it has been very helpful and
interesting to have spent the day listening to my colleagues
talk about New Orleans and access to primary health care as it
is at this time, and how it has changed compared to immediately
before and after Katrina.
HRSA and the rest of the Department I think have worked
collaboratively to address these challenges. CMS certainly is
the part of the enterprise that looks at payment. But HRSA is
concerned about access through health centers, work force. Our
colleagues in SAHMSA would be very interested to hear the
challenges that the city still faces in providing access to
adequate mental health services. So certainly, sir, I will take
your challenge and your charge back to the Department and see
what we might do.
We have been working together collaboratively. But this
might be an opportunity to look at that and see what the next
phase might most appropriately be.
Chairman Towns. Thank you very much, Dr. Brand.
Mr. Levine, can you give me a broad outline of your
administration's plan to build a replacement facility for the
now-shuttered Charity Hospital? When will construction begin?
How will it be financed and what scope and size? Is there
anything that the Congress can do to facilitate this?
Mr. Levine. Thank you, Mr. Chairman. We have taken several
steps to move the process along to the extent that we can.
Obviously, the financing is the big piece of this that hasn't
been resolved. We are still, unfortunately, in the arbitration
phase with FEMA at the moment. We believe that the State has
made adequate, has provided adequate evidence that the State is
owed $492 million under the Stafford Act. FEMA's last offer was
$150 million, up from the original offer of $26 million or so.
We are in the process of acquiring the property. The
architects are doing the design planning phase of the project.
So all the things that can be done while we work out the
financing piece of this is critical.
The other thing that we have done is we have completely
changed the model from the old Charity Public Hospital model.
We have actually looked at what happened in Atlanta with Grady,
we have looked at Tampa General, we looked at others--Shands
Hospital in Gainesville with the University of Florida. We have
looked at models of teaching hospitals that used to be public
but have converted to the non-profit model. And that is what we
have done. We entered a memorandum of understanding between
Tulane, LSU, and the State that was signed about 2 or 3 months
ago.
So all of those pieces have been put in place. The one
piece that has not been put in place is the FEMA piece of this,
which is substantial. The way the financing is supposed to work
is, the State has committed $300 million. We had estimated the
$492 million from FEMA. And then the difference between that
and the $1.1 billion and $1.2 billion was going to be financed
through the debt markets. If FEMA doesn't come through with the
significant amount of money, if the arbitration doesn't go our
way, that could really imperil our ability to finance this
hospital, given the situation. We would have to finance more
than the estimated $400 million that we had planned on.
So irrespective of whether somebody believes we should
rebuild the old hospital or build a new one, it is all academic
if we can't get the money from FEMA. So the question about what
Congress can do, to the extent that FEMA falls short due to the
arbitration process, if it doesn't go our way, certainly
Congress can step in and provide funding that would bridge that
gap. We aren't asking for that at this point. That is certainly
in the purview of Congress. But we are trying to work within
the scope that has been laid out by FEMA.
Chairman Towns. On that note, I yield to the representative
from the area.
Mr. Cao. Thank you, Mr. Chairman. And Mr. Chairman, I am
very glad to hear today from the GAO that we have been using
the money responsibly. Because traditionally, we have had some
negative images with respect to how money is being spent.
With that being said, I was a little bit disappointed, Dr.
Crear-Perry, to hear that there are $4 million for mental
health that is left unspent by the city. And you come here to
testify of mental health needs. Can you explain with respect to
that discrepancy?
Dr. Crear-Perry. We don't have money for mental health in
the city.
Mr. Cao. I am sorry?
Dr. Crear-Perry. We don't have a mental health grant for
the city.
Mr. Cao. I received information from very secure sources
that the city does have $4 million in mental health money left
unspent.
Dr. Crear-Perry. I am not sure.
Mr. Cao. Can you look into that, if you don't mind?
Dr. Crear-Perry. Yes.
Mr. Cao. And Mr. Williams, do you have any comments with
respect to that?
Mr. Williams. I believe it would be a strange coincidence
if it wasn't the, if this wasn't the $4 million carve-out from
the Primary Care Access and Stabilization Grant that was
specifically earmarked for the city of New Orleans Health
Department to address not just mental health, although that is
an allowable expenditure of the primary care grant funds, but
also to address health care needs in particularly under-served
areas and to provide the dental services, which are up and
running. They got off to a slow start spending that money, but
they are well underway to make good use of it at this point, as
far as I know today. We can get you more information on that.
Mr. Cao. So of the $4 million, which portion of it was
spent on mental health, which portion of it was spent on the
dental trucks?
Dr. Crear-Perry. When we applied, we didn't apply
specifically for mental health. We could use it for dental and
the New Orleans East Clinic. So we have spent it on dental and
New Orleans East Clinic. So we are on track to spend all of our
allocation by the end of the grant. We will have no money left.
Mr. Cao. OK. Dr. Brand, I was looking at some of the grant
allocations that HRSA has granted to the area. I have noticed
that a large portion of it was concentrated in the downtown and
uptown area, where, the areas around the fringes, the northeast
areas, St. Bernard, those areas in Waggaman and Westwego, there
have been very little being done for those areas. Can you
address that, please?
Ms. Brand. Certainly. I believe that Administrator
Wakefield has begun talking, dialoguing with you and your staff
about the fact that those areas do not have ready access to
federally qualified health centers. We continue to work with
the Primary Care Association to look at those areas where we
might, should resources be made available to do a new expansion
or provide a new access point. There will not be resources
available for a cycle in 2010. We don't know what the situation
will be for 2011, because that budget is still being developed.
But certainly, we will work with folks in that community. We
will work with the Primary Care Association to help, an
organization that is ready to stand up and be prepared to
either be an FQHC or lookalike, be prepared.
The other opportunity, should resources be available, is
something called a planning grant that helps a community
organize and be prepared to apply, and perhaps be more
successful in that application process.
Mr. Cao. Mr. Levine, I know that the State has a terrible
FMAP problem. Can you please explain to us how would the FMAP
problem affect the issue of the poor in the district, and also
I would like to know whether or not the State has an audit
system with respect to how money is being spent by the city as
it comes down from the State.
Mr. Levine. Thank you, Congressman Cao. The FMAP problem is
the single biggest problem our State faces right now, with
financing for the poor. We can't sustain nearly a $1 billion a
year reduction in our funding for Medicaid. It would trump
everything, all the progress that has been made here. Whether
we talk about the expansion, I know there is a potential
expansion of Medicaid in the reforms. In the House bill, it was
133 percent, in the Senate, it is 150 percent.
For us to go from where we are today, where currently we
have a $275 million deficit in our Medicaid program this year,
into a situation next year where we face a $900 million
shortfall, and then go into a period where we then have to do
an expansion of Medicaid, it couldn't be done. The maintenance
of effort requirements under the stimulus, and then in both of
the House and Senate bills, would really put a lot of pressure
on provider rates and really, I think effectively make our
program insolvent.
So we really need a solution to this FMAP problem. All of
the good work that has been done, what we talked about earlier
about potential solutions to the PCASG grant, for instance,
allowing us to use CDBG money that is unspent, or applying for
a DSH waiver that would allow us to use disproportionate share
funding for community-based clinics, we can do those things.
But we also have to provide State match.
With the decrease in Federal match that we are facing, we
are not capable of doing that. So I think that the fundamental
problems here are: (a), fixing the FMAP problem, (b),
acknowledging this DSH audit rule and the quarter of a billion
dollar per-year impact it is going to have on our State, in
addition to the FMAP problem, and then (c), the $30 million
problem we are going to have when this grant runs out in less
than a year. These are three converging factors that any one of
which would be devastating. But all three of them are virtually
impossible for the State to be able to overcome on our own.
Mr. Cao. Does the State have an audit system to ensure that
money is being spent by the city?
Mr. Levine. As it relates to funds that come through the
Department, we do. And we have an internal audit function. We
also have the ability through our contract to review all such
expenditures, as does the legislative auditor, I believe, have
the authority to audit any grant funds that come through our
department.
Mr. Cao. Could you provide us with a copy of the audit?
Mr. Levine. Sure. I won't say that--have we done any audits
at this point? Yes. The answer is yes.
Mr. Cao. Mr. Chairman, if you will allow me one more
question.
Chairman Towns. Sure. I will extend the gentleman's time
for another minute.
Mr. Cao. Thank you very much.
I know Dr. Crear-Perry has addressed the issue of the New
Orleans East and the lack of hospitals out there for New
Orleans East and St. Bernard. Dr. Brand and Mr. Levine, is
there any way both of you or both of your organizations can sit
down and discuss the problem and come up with some kind of
solution in connection with Tulane and LSU to see how we can
address that particular need out there, for approximately
120,000 people? 120,000 people right now do not have access to
a hospital.
I know, I live out there in New Orleans East. About 2 years
ago, I had to drive my father close to 40 minutes to get him to
the nearest emergency room. He is a diabetic and he has some
complications. We had to fight traffic, drive over the high
rise, which for the people of New Orleans East, almost serves
as a psychological block for many of them. So if you could do
that, I would really appreciate it.
Ms. Brand. I think the administration stands ready to work
with the Congress, the State, and the local partners to address
all service gaps. Certainly we would be happy to meet with
them.
Mr. Cao. Thank you very much. That is all I have, Mr.
Chairman.
Chairman Towns. Thank you very, very much. Let me thank all
of you for your testimony. You have been very, very helpful and
we look forward to working with you in the days and months
ahead, and to move some of these things forward. I think under
very difficult circumstances and conditions that you have been
able to do some amazing things. I want you to know we really
salute you for that.
Again, thank you so much for your testimony. This hearing
is adjourned.
[Whereupon, at 3:20 p.m., the committee was adjourned.]
[The prepared statement of Hon. Diane E. Watson follows:]
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