After the Storm — Health Care Infrastructure in Post-Katrina New Orleans

On September 2, 2005, when Wildlife and Fisheries boats finally evacuated patients and staff from Charity Hospital in New Orleans, we could not fully comprehend the devastation of our health care infrastructure. Reflecting recently on the vast scope of the rebuilding effort, Fred Lopez, vice chair for education at Louisiana State University (LSU) School of Medicine, observed, “The desperate week we spent inside Charity after Katrina is the one that everybody saw on CNN, but that was the easiest week of the last six months.”

Immediately after Hurricane Katrina, our crisis was acute, our options limited, and our decisions necessarily quick. Now, with the crisis in the chronic phase, options backed by conflicting interest groups abound, resulting in cumbersome decision making and dangerously slow implementation. During the crisis, two principles contributed to survival: initiative for self-rescue and professional teamwork. As we heal our infrastructure, these principles continue to guide us.

Although many citizens have yet to return, area hospitals are scrambling to meet local needs. The population of metropolitan New Orleans is approximately 24 percent smaller than before the hurricane, but only 15 of 22 area hospitals are open, with 2000 of the usual 4400 beds. According to data from the Times-Picayune, before the storm, New Orleans had only 3.03 hospital beds per 1000 population, as compared with the average of 3.26 per 1000 for U.S. cities; today, there are 1.99 per 1000. “The number one current problem is total hospital capacity,” says Joseph Uddo, chief of general surgery at East Jefferson General Hospital in neighboring Jefferson Parish. “Emergency department patients can't move into the hospital because beds aren't available. We have no surge capacity.”

Moreover, open hospitals must deliver ever greater amounts of uncompensated health care. Patrick Quinlan, chief executive officer (CEO) of the Ochsner Clinic Foundation, says uncompensated care in his facility has tripled since Katrina. “Many people have lost their jobs, and we have throngs of transient workers in town without health insurance,” reports Les Hirsch, CEO of Touro Infirmary. Reimbursement for uncompensated care has yet to come, and, Hirsch notes, there is “a huge debate regarding how best to have uncompensated care dollars follow the patients, rather than following the hospitals.”

Common themes at all facilities include complications in patients with untreated chronic diseases, particularly hypertension, diabetes, and AIDS (see box). “These people come in with extremely severe problems,” notes Alfred Abaunza, chief medical officer of West Jefferson Medical Center. “Diabetics have been off their insulin for six months. They come to us in diabetic ketoacidosis.”

Many believe that mortality has also increased substantially, although specifics are difficult to obtain — the Louisiana Department of Health is still struggling to complete the compilation of 2005 data. As a crude indicator, there were 25 percent more death notices in the Times-Picayune in January 2006 than there were in January 2005. Stress exacerbating underlying health problems is blamed for some deaths. Post-traumatic stress disorder and suicide remain tangible public health issues. There are insufficient numbers of mental health facilities and care providers to deal with the crisis.

Immediately after Katrina, victims waited days for rescue. Similarly, assistance for the chronic phase of the health care crisis has been excruciatingly slow to materialize. When asked what government had contributed to the efforts of the Ochsner Clinic, Quinlan said, “Nothing. We have asked and asked [authorities] for fair compensation, and perhaps we will get it eventually, but we cannot go on indefinitely providing uncompensated care.”

Approximately 40 of Ochsner's 600 physicians and 1500 of its 7400 other employees resigned after Katrina — because their spouses no longer had local employment, children's schools were closed, or housing was not available, among other reasons. One New Orleans nurse who resigned her post in frustration explained that “the patient rooms are crowded, the staff is stressed, and there are serious supply shortages. Our standards of quality are tough to meet when the system is so strained.” Staff shortages cause bottlenecks at many hospitals. Elective surgery has been postponed at some hospitals owing to a lack of anesthesiologists. Hirsch reports that to address its shortage of nurses, Touro Infirmary is paying those willing to come to New Orleans “a 50 to 100 percent premium.”

The need for creative solutions to the bed shortage has led to new alliances among hospitals. Touro is collaborating with LSU and Tulane; Ochsner helped LSU to open a trauma center; LSU and the Veterans Affairs (VA) hospital are pooling resources for a hospital to replace flood-damaged facilities; and the VA now contracts beds from Tulane. Still, some indigent patients must go to a safety-net hospital 75 miles away in Baton Rouge to find care. Consumers remain confused about which hospitals are open and what services they provide.

Photograph by Michael Brumlick, Ph.D., Tulane Medical School, 2005.

In this environment, medical education has suffered, but both local medical schools are tenacious. Tulane laid off one third and LSU lost one quarter of their medical school faculties. Other faculty members, without assurances regarding their future, continue to leave. Tulane's medical students were welcomed by Baylor Medical School in Houston, and its house staff were dispersed to other hospitals. LSU decamped temporarily to Baton Rouge, where students and professors are living on a ship on the Mississippi River and commuting to classes at a conference facility. Hospitals throughout Louisiana accommodated LSU's residents. Training continues at both medical schools, because some dedicated faculty members are willing to commute, relocate, sleep on a boat, or do whatever is necessary in order to go on teaching. Some residents and fellows drive hundreds of miles weekly to work at temporary hospital assignments.

Despite these difficulties, Tulane's internal-medicine training program has lost only 6 of its 90 residents. Pediatric training at Tulane has been gravely affected by Charity's decision to close its inpatient pediatrics program in the face of a diminished population of children: 11 of 24 medicine–pediatrics trainees have left. But overall, says Jeffrey Wiese, medical-residency program director, “our residents learned a lot of personal and character lessons that, in the end, will make them better physicians.” Moreover, both schools are heartened by the number and quality of applicants for next year.

Leaders from all health care sectors have emphasized the importance of graduate medical education (GME) to the health care infrastructure. Medical residents are the care providers for most underinsured patients in any major U.S. city, and the need for them in post-Katrina New Orleans is self-evident. Moreover, physicians trained at LSU and Tulane have historically stayed to practice in Louisiana. “If we don't support GME, then we do serious damage to the future of health care in this state,” asserts Tulane's Ron Amedee, associate dean for GME.

Nonetheless, protecting GME appears to be a low priority for government agencies. Tulane relies on the Hospital Corporation of America, an 80 percent owner of Tulane Hospital, to sustain residents' salaries while funds are held up by the Centers for Medicare and Medicaid Services (CMS), which funds specific hospitals, not individual residents. CMS says that a waiver is being negotiated to mitigate the deficit in the salaries of displaced residents. The pace of bureaucratic change could be lethal to training programs.

Early after Katrina, a policymaking group, facilitated by the Public Health Service, developed “A Framework for Rebuilding the Health Sector of Metropolitan New Orleans.” Participant Karen DeSalvo, chief of general internal medicine at Tulane, notes that the development of this framework brought together diverse members of the public and private sectors. Though the group acknowledges offering a utopian vision to a city of few resources, DeSalvo says they reached agreement in key areas that are necessary for progress. In further work with the health care task force of Mayor Ray Nagin's Bring New Orleans Back Commission, she adds, the long-term–redesign group “looked at best practices around the country, and at models of health care delivery that focused on the underserved.” Governor Kathleen Babineaux Blanco's Louisiana Recovery Authority hopes to adapt the Institute of Medicine's “Crossing the Quality Chasm” concept of a safe, effective, equitable, patient-centered, sustainable system for Louisiana.

Meanwhile, seven months after Katrina, health care here remains unacceptably primitive. Legislative action is warranted to ensure that CMS dollars for GME salaries follow residents, rather than institutions, and that health care reimbursements for the uninsured persons follow patients, rather than hospitals. The absence of chronic care facilities contributes to the lengthening of stays in acute care hospitals whose costs exceed CMS reimbursement, and these additional uncompensated expenses may soon force recently reopened hospital beds to close again. Without rapid, coordinated, and effective help from government agencies, we fear that disproportionate human suffering and death will continue to plague greater New Orleans.