Hurricane Lessons

"Once destroyed, the major components of a health care delivery

Hurricanes Katrina and Rita were the worst natural disasters in U.S. history, devastating Louisiana, Mississippi, and Alabama. Months after the storms, the Gulf Coast's health care delivery remains in ruins, and the effects of displaced patients have rippled throughout the region and across the country.

Displaced Gulf Coast physicians, nurses, medical students, and other health care professionals continue to struggle to re-establish their professional careers. Residents returning to New Orleans and other communities are finding they may no longer have employer-sponsored health insurance, their physicians and their medical records can't be found, hospital emergency rooms - at least those that are open - are overcrowded, and there are few pharmacies, few nursing homes, and no psychiatric hospitals.

What lessons does the Gulf Coast's devastated public and private health care delivery system provide? As the song lyric goes, "You don't know what you've got 'til it's gone...."

Swept Away

No one appreciates the wonder of our complicated health care infrastructure until it's no longer there: no functioning hospitals, no emergency rooms, no doctors' offices, no trauma care, no personal medical records, no ambulances, no 24-hour drugstore. Think about the number of times a week or a month you or your family use a direct or indirect health service. According to The Brookings Institution's Katrina Index Tracking Variables of PostKatrina Reconstruction, January 2006 Update, "Most schools and hospitals in Orleans Parish remain closed....only 32 percent of the city's hospitals are now open." The report continues, "The bottom line: it continues to be a very risky decision for many of the displaced households to return to the area, since all of the key necessities are in scarce supply, and it is not at all clear when or if they will be brought back on line."

Prior to Katrina and Rita, Orleans Parish had 22 functioning private and public hospitals, Jefferson Parish had 14 hospitals, and St. Bernard Parish had 2 hospitals. In January, Orleans had 7 hospitals open, Jefferson was better off with 13 hospitals open, and St. Bernard still had no hospital open. The Louisiana Hospital Association reported to Health and Human Services secretary Michael Leavitt in late October 2005 that 11 hospitals were closed indefinitely, 10 were closed temporarily, and only 6 were functioning on a partial basis. The New Orleans area is functioning on a third of its former hospital capacity.

A report prepared by the University of North Carolina's School of Public Health estimated that more than 6,000 Gulf Coast physicians were relocated as a result of the hurricanes and approximately 1,500 had returned by the end of 2005. The hospitals that are open struggle to find nurses and other health care professionals such as imaging techs, surgical techs, respiratory techs, and lab techs to staff the inpatient beds and outpatient services. The region's trauma center is closed and unlikely to reopen. Trauma care in Louisiana is now based in Baton Rouge. Only 4 out of 38 nursing homes are open in the New Orleans area.

Patients are backlogged in other Louisiana, Mississippi, Texas, Arkansas, Alabama, and Florida hospitals because there aren't enough post-acute places (read nursing home beds) available throughout Louisiana. Physicians who have returned, like others in small business, are struggling to re-establish themselves and are turning to local hospitals for direct financial support until their practices are re-established. Many of these hospitals are hard pressed to provide this support.

Those hospitals face a dramatic shift in their payer mix - more Medicaid and less private health insurance. This means hospitals (and other providers) can no longer shift the effects of under-reimbursed care to private insurance. Hospitals are also facing inflated labor and other operating expenses without corresponding payment increases. Bankruptcy may be their only option.

Catch-22

The classic "Catch-22" is Charity Hospital, New Orleans' oldest hospital. To care for the community after the storm, the hospital established a tent city in a local park for their emergency and intensive care departments with tents provided by the Department of Defense (think MASH 4077). This facility with its dedicated staff of physicians, nurses, and other allied health professionals treats all patients-the insured, the uninsured, and whomever. Because the "tents" don't meet Medicare's standards for quality emergency care, however, Charity can't bill for the services they provide.

Prior to Katrina and Rita, New Orleans was a center of undergraduate and graduate medical education with more than 1,000 interns and residents toiling in area hospitals and clinics. Even before the storms, the graduate medical education programs were suffering from a lack of patient volumes. With the area's population reduced by two-thirds, rebuilding these programs to their former status may not be feasible.

What Lessons?

What lessons does the devastation of the Gulf Coast's health care delivery hold for the rest of the country?

1. Health care is a critical part of any region's economy - too critical to be taken for granted. Like education, health care is vital to sustaining a region's human capital (that is, its labor force). A vibrant economy depends on daily interactions of its financial capital; its private and public infrastructure (power, water, sewer, telecommunications, transportation networks, etc.); private commercial enterprises; and public and private social and civic institutions such as health care, education, law enforcement, and civil and criminal justice institutions. (Perhaps health care is truly a public good, after all.)

2. Once destroyed, the major components of a health care delivery system will take years to rebuild. Under the best of circumstances, it takes at a minimum of three to five years to build (or rebuild) an entire 200-plus bed hospital. Physician offices, clinics, and outpatient surgery centers can take 12 to 18 months to build. Nursing homes and other post-acute care facilities also take years to build. But people need care in the short term, like NOW!

3. No hospital can afford enough insurance. Property and casualty insurance doesn't cover all losses. Every hospital, public or private, was underinsured.

4. A cost-effective redesign of a region's total health care system is impossible under our current fragmented and dysfunctional health care financing, reimbursement, and payment system. A health care delivery system that is now almost entirely dependent on government (Medicaid/Medicare) programs' reimbursement can't generate sufficient revenues to reinvent and rebuild itself without substantial direct public funding-for example, government grants, loans, or subsidies.

5. Cost-effective redesign can't focus on expanding primary care and preventive care if the payment mechanisms still reward sick care. A reimbursement system that doesn't pay for routine podiatry care for a diabetic's feet but does pay $30,000 for a foot amputation, obviously doesn't have the right incentives. The system will rebuild but on a smaller scale than its former high-cost, acute-care-driven facilities, leaving primary and preventive care still lacking.

6. Mental health and post-acute care need to be part of the continuum of care. Post-traumatic stress requires treatment.

7. Public health can't just be the stuff that private health care can't make money from. Rich or poor, everyone's health is connected.

8. No more paper records! The VA's system of electronic medical records allowed VA patients evacuated from the Gulf Coast to be accessed from VA sites across the country. The chronically and critically ill deserve to have their medical information readily available.

9. Where does graduate medical education fit? How can we better train tomorrow's health care professionals?

10. Regardless of your health insurance status, you will be out of luck if the only hospital functioning is two parishes or counties away, the cell phones don't work, and the highways are in gridlock. There is a different meaning to "consumer-driven health plan" when there isn't any place to "shop" for your care.

11. Don't take your health care delivery for granted!

There is much to be learned as the Gulf Coast works to rebuild and re-establish its health care system. Other areas should welcome the opportunity to study this laboratory. It may be a once-in-a-lifetime chance to get it RIGHT!