In the year since Hurricane Katrina hit the nation's Gulf Coast, providing healthcare to residents in one area just outside of New Orleans has been similar to a stroke patient's recovery, according to Michael Pisciotta, administrator at St. Bernard Health Center in Chalmette, La. "Patients have a stroke and can't walk," Pisciotta said, describing the region immediately after the storm. "By December, we could stand. By March, we were using the parallel bars. Today, we're up and walking."
Pisciotta is among the administrators on the Gulf Coast battling to keep their systems afloat amid extraordinary circumstances. Before the storm, he had worked as an assistant administrator for Chalmette Medical Center, a 194-bed hospital owned by Universal Health Services, a $3.9 billion for-profit hospital company. UHS also operated 350-bed Methodist Hospital in New Orleans, and River Oaks Hospital, a 126-bed psychiatric facility in Jefferson Parish. Both Chalmette and Methodist remain closed, while River Oaks reopened in November 2005.
The town of Chalmette's dramatically smaller population no longer is served by a full-fledged hospital, and its current provider is the St. Bernard center, a makeshift clinic operated by two Roman Catholic health systems.
After Chalmette Medical Center was destroyed by the storm, the U.S. Public Health Service provided healthcare in St. Bernard Parish from October 2005 until April 2. The next day, the Franciscan Missionaries of Our Lady Health System in Baton Rouge, La., together with Ascension Health, took over, providing services in a triple-wide trailer in the parking lot of a Wal-Mart Supercenter in Chalmette, a town about seven miles outside of New Orleans. On May 29, the health center expanded to 22,000 square feet in 26 connected, air-conditioned trailers.
The story of the St. Bernard Health Center demonstrates the myriad challenges that Louisiana's health system has endured in the past year, is dealing with today and will face in the future. Those challenges include the severe damage to or complete loss of entire facilities and equipment; depletion of the healthcare workforce; increases in uninsured care and questions about the state's charity-care system; physical, emotional and mental issues that have affected every person no matter the amount of loss; and corporate responses that suggest a commitment to patient care but focus more on the corporation's own health.
But the story also shows the positive results that can be achieved when the main goal is to provide healthcare for a community.
Pisciotta's analogy to a stroke victim's recovery reflects the attitude of many residents of New Orleans and its surrounding parishes, and especially of those who work in Louisiana's troubled healthcare system: As with any recovery, time will likely prove to be the best treatment. Progress in rebuilding the region's healthcare infrastructure has been slow but steady. In a poll of a nationally representative sample of more than 1,200 respondents conducted by the Henry J. Kaiser Family Foundation in June, 70% said they thought most people affected by Hurricane Katrina have not gotten the help they need with housing, healthcare and restoring their lives. Also, 52% said there is still major work to be done in the area, a statistic confirmed by a visit to New Orleans almost a year after the storm made landfall on Aug. 29, 2005, and the city's levees broke.
Much of the work involves the state's hospitals and medical centers. The Louisiana Hospital Association reports that seven acute-care hospitals are still closed, seven have reopened, and three -- 443-bed East Jefferson General Hospital in Metairie, 350-bed West Jefferson Medical Center in Marrero and Ochsner Health System in New Orleans -- have remained open since Katrina. In March, the Government Accountability Office reported that the number of staffed beds in New Orleans and surrounding parishes had dropped by 51.4% to 1,984 in February from 4,083 before the storm.
The decline in the number of area physicians also has been significant. The Louisiana Department of Health and Hospitals cited a Blue Cross and Blue Shield of Louisiana report that said 1,502 physicians in Orleans, Jefferson, Plaque-mines and St. Bernard parishes filed claims in July, down 51.4% from 3,091 a year ago. In Orleans Parish alone, which contains the city of New Orleans, the number of physician claims fell to 510, down 79%.
Updated population estimates for the state will not be available until December (and not until next spring by parish, which is the Louisiana equivalent of a county), according to a spokeswoman for the U.S. Census Bureau. But earlier this year, the bureau reported household population estimates (which do not include residents living in trailers) of 2.98 million for the state, down 9.7% from July 2005. Orleans Parish had about 158,000 residents, down 63.8%, while St. Bernard Parish saw its population plummet to roughly 3,300, down 95%.
For those who stayed or returned to Chalmette, the St. Bernard Health Center is "the best building in the parish," Pisciotta said. "It's cool. It's clean." Unless viewed first from the outside, it would be hard to know the facility is composed of trailers.
Exxon Mobil Corp., which has a refinery in Chalmette, contributed $500,000 to the center. "Healthcare is a key component in the rebuilding and recovery (of) the area," said Russ Roberts, an Exxon spokesman, adding that it was "an easy decision for us" to make the donation.
By increasing their presence in the area, not-for-profit hospitals have supported Roberts' statement that healthcare is essential to recovery, while for-profits have backed away. Last month, Ochsner, which already operates several campuses in the area, announced plans to buy Memorial Medical Center, Kenner (La.) Regional Medical Center and Meadowcrest Hospital, Gretna, from Tenet Healthcare Corp. (July 24, p. 7). Combined, the hospitals are licensed for 727 beds.
"The emphasis will have more of a `what's good for the community' than `what's good for the company,' " said Jim Aiken, an emergency physician who serves in several capacities at Louisiana State University, including as medical director for emergency preparedness at the Medical Center of Louisiana at New Orleans, and as the medical director of the LSU/Elmwood Trauma Center at Elmwood Medical Center in New Orleans, which began providing services in April. LSU leases space from Ochsner.
In the case of the St. Bernard Health Center, the two Catholic systems plan to maintain a presence in the area, although that presence is still undefined. "There does seem to be a need for a hospital," said George Burgess, vice president of innovation and technology for the Franciscan system. "However, we would like to gather some data to define the scope of whatever we put there in a planned fashion that would support the local needs as defined by those who live there."
Ascension had provided services in the area prior to Katrina with its Daughters of Charity Services of New Orleans Health Center that was destroyed in the storm. It reopened in a space rented from the Louisiana Office of Public Health in suburban Metairie and is preparing to open another location. "We're very excited about the partnership" with Franciscan, said Susan Nestor Levy, senior vice president of advocacy and external relations at Ascension Health. Nestor Levy also said Ascension plans to continue providing services in New Orleans, but the long-term plan for the St. Bernard partnership with Franciscan is undecided.
Unlike the two systems committed to remaining in the area, UHS is still evaluating what role, if any, it will have there. Marc Miller, vice president of the eastern region of the acute-care division for UHS, said there are no definite plans to reopen the Chalmette campus because of its severe damage. "For the first six to eight months, there were 6,000 to 8,000 residents there (in the parish), now (there is) more. Certainly, a full-scale hospital is not appropriate for that. I don't think there was a need for us to jump back in at this point," he said, adding that UHS is continuing to evaluate reopening the Chalmette facility as well as Methodist. Any reopening of the Chalmette facility would "require almost a total rebuild on the site," he said.
Meanwhile, the St. Bernard center will continue to provide services, for which the need is increasing as residents and volunteers sustain injuries as they rebuild. Bryan Bertucci and Paul Verrette, physicians who work at the center, stressed a need for a hospital and equipment as the center sees an average of 95 patients a day, seven days a week. With a new computer system in place, the center expects to have electronic medical records within the next two months. Urgent-care services should also be available by then. "Working for Franciscan is different," Pisciotta said. "Our focus is treating those in need, and finances is No. 2. The reason we're in St. Bernard Parish is not to make money; it is to help our brothers and sisters in need."
The health center in St. Bernard provides a glimpse of a larger landscape that paints a sobering, but not hopeless, scene of New Orleans. Ask anyone from a hospital chief executive to the employee at the tourist information booth next to the city's famous Cafe Du Monde coffee shop, and you will learn that residents are eager for people to return to the city, either to live or to visit. And the healthcare system, like all other industries, is depending on that for its survival.
"You can't recruit people to come work in a FEMA trailer," said John Matessino, president and chief executive officer of the Louisiana Hospital Association. "The situation is getting better. You don't fix that in 12 months -- it will take years to get that back. There are people who will never come back, and I understand that." Fred Cerise, secretary of the Louisiana Department of Health and Hospitals, who agreed that recruiting and maintaining the workforce is a significant problem (See story, at top right), said Katrina laid bare the flaws in Louisiana's healthcare infrastructure.
"It highlighted the problems with our fragmented delivery system," said Cerise, who chairs the Louisiana Health Care Redesign Collaborative, established by the governor to develop and implement a blueprint for an evidence-based, quality-driven healthcare system in the state.
By Oct. 20, the collaborative is expected to submit to HHS a comprehensive systemwide Medicaid waiver and Medicare demonstration proposal for Jefferson, Orleans, St. Bernard and Plaquemines parishes. On its Web site, the collaborative says that once implemented, "This redesign of Louisiana's healthcare system generally, and greater New Orleans specifically, will serve as a model for the nation."
Katrina has forced government officials and healthcare providers to take a hard look at the state's charity-care system, which has a long history and won't be changed easily. Charity Hospital was founded in the late 18th century; in the first half of the 20th century, Gov. Huey Long expanded the charity system and helped establish the Louisiana State University Medical School. Today, the closed Charity and University hospitals, known as the Medical Center of Louisiana at New Orleans, are part of the state's system of 10 public hospitals; eight are operated by the LSU Health Care Services Division and two by the LSU Health Sciences Center in Shreveport.
The Medical Center of Louisiana "served as the primary safety net hospital for many local residents," the GAO wrote in its report. "About half of its patients were uninsured, and about one-third were covered by Medicaid. In fiscal 2004, it provided more than 25,000 inpatient admissions, over 300,000 clinic visits and 135,000 emergency visits."
With Charity remaining closed with no plans to reopen, and University expected to reopen this fall, some of those visits are now made to an emergency-services unit in a former Lord & Taylor store in New Orleans, where Aiken serves as an emergency physician. "We can do the initial assessment and stabilization, but if we need a hospital bed, that's when it's a challenge," he said.
Without these major charity-care providers, private hospitals such as Ochsner, East Jefferson and Touro Infirmary -- which have sustained significant operating losses -- are now providing more care to the region's uninsured. At 250-bed Touro in New Orleans, the number of uninsured patient visits from Jan. 1 to June 30 increased more than 80% from the same period in 2005, according to a hospital spokeswoman.
Leslie Hirsch, who started as Touro's CEO a week before Katrina, said reopening was like changing a tire on a car that was moving at 60 mph. To date, the hospital has lost about $65 million, about one-third of that in damage. East Jefferson's percentage of uninsured cases is about 8% today, compared with 3% before the storm, according to Pika Sdrougias, government relations officer at the facility. Sdrougias said the hospital's total loss for 2005 was $41 million, and it is losing about $3 million a month. And Ochsner CEO Patrick Quinlan said his hospital's uninsured patient load has tripled since last year. The system has lost about $80 million since the storm, he said.
In the spring, the federal government dispersed $383 million to Louisiana to reimburse hospitals for uncompensated care of Katrina evacuees for the period of Aug. 24, 2005, to Jan. 31, 2006. From February until June, $40 million in state funding was provided to service district hospitals created by the state or parish and $12 million to private hospitals, according to the LHA. In June, the state passed legislation that will earmark $120 million for community hospitals in 2007.
"There's not a day that goes by that Katrina has not impacted," said Touro's Hirsch. "It was our 9/11. It will take a long time for it ever to be the same -- and who knows if it ever will be the same."
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