March 22, 2007
Charity Hospital rests on Tulane Avenue in downtown New Orleans like a beached whale... DESOLATE AND ABANDONED.
A once-glorious, thriving behemoth where generations of Tulane physicians received training, "Big Charity" remains in ruins after soaking for weeks in post-Katrina floodwaters. Built in 1939, the 57,000-square-foot, limestone building is a memorial to the Charity system's 270-year history of serving the city's indigent ill and injured, as well as a testament to challenges in delivering health care in the city's future.
Before Hurricane Katrina, 62 percent of the New Orleans citizenry received health care at Charity and 70 percent of Louisiana's physicians trained in its wards.
When Patrick Breaux (M '66), a cardiologist who was chief resident on the Tulane service at Charity, surveys the present scene, he can't help but recall the glory days of the hospital, venerated by its physicians-in-training for the wide variety of illnesses and trauma that represented a panoply of experiential learning.
Charity was not only the place where the preponderance of citizens without medical insurance received care for chronic diseases but it also was known for its excellence in emergency and trauma care.
"It was our whole world," says Breaux. "We didn't know anything else. On Saturday evenings, it almost became our entertainment--we called it the knife and gun club. It presented an opportunity for you to seek your own level."
Breaux, who completed his internship, residency training and cardiology fellowship at Tulane, was president of the Orleans Parish Medical Society when Katrina whacked the Crescent City. In those pre-storm days, he could not have imagined the complete shutdown of Charity Hospital or a future where the viability of the Charity healthcare system and residential training programs were in doubt.
Charity's closure is a blow to both recipients and providers of health care in the greater New Orleans area, yet it is only one facet of an industry abruptly shattered and still attempting to put its pieces back together. After five days of evacuating patients in New Orleans hospitals, the only functioning facilities in the metropolitan area were three suburban hospitals in neighboring Jefferson Parish.
Among the Katrina casualties were major teaching partners for Tulane and Louisiana State University medical schools, including two campuses of the Medical Center of Louisiana at New Orleans (Charity and University hospitals), Tulane University Hospital and Clinic, and the Veterans Administration Hospital.
"In the immediate post-Katrina environment, Tulane was the largest ambulatory care provider in Orleans Parish, with clinics that remained open seven days a week," says Paul K. Whelton, outgoing senior vice president for health sciences. "Our medical personnel provided free care for about 400 patients per day in the absence of any formal healthcare infrastructure. Our faculty and residents provided care under awnings, in police precincts, in tents and in parking lots."
The healthcare system remains fragile even now, with reopened hospitals, including Tulane University Hospital, operating near or at capacity. Charity, the VA and University hospitals, as well as Memorial Medical Center, remain closed. Many patients who had health insurance before Hurricanes Katrina and Rita now have joined the ranks of the uninsured. For example, of the more than 800,000 individuals who received group insurance from BlueCross BlueShield of Louisiana, about 30,000 lost their employer-provided coverage.
In New Orleans alone, the proportion of uninsured is more than 40 percent since Katrina. With the Charity public health system unavailable in New Orleans, the charity care provided by Tulane to uninsured patients increased by 561 percent, while the number of admissions at Tulane University Hospital in August 2006 was down by 26 percent compared to August 2005.
The widespread loss of patient records put large numbers of patients at risk. Paper medical records housed in many physicians' offices were destroyed during and after the storm. Thousands of ill patients evacuated without their medications or prescriptions.
Doctors and hospitals in surrounding areas were confronted with treating new patients who in effect had no medical history or other pertinent information. While many evacuated residents have yet to return to the area, physicians who had been practicing in the New Orleans area left in even greater proportions than the general population. Statistics released in spring 2006 showed the area had lost 77 percent of its primary-care doctors, 70 percent of its dentists and 89 percent of its psychiatrists. In fall 2006, statistics from the Louisiana Department of Health and Hospitals revealed that the number of physicians in the area registered with Blue Cross/Blue Shield was down 51.4 percent from pre-Katrina levels.
Before the first anniversary of Katrina's landfall, the federal government designated Orleans Parish a health professional shortage area, meaning the parish had no more than one primary-care doctor per 3,000 individuals, one psychiatrist per 21,000 and one dentist per 4,000. In addition to physical health, mental health in the post-Katrina scene is of great concern.
Post-traumatic stress disorder has affected every age group in the areas damaged by the hurricane. Some professionals estimate that half a million people in the Katrina-affected area need mental health care, and the shortage of psychiatric hospital beds for inpatient care is particularly acute.
"We really have a mental health crisis, and we've had it for months," says Tulane psychiatrist Janet Johnson, who has been volunteering time and training psychiatry residents at various clinics. The legacy of Hurricanes Katrina and Rita is that many in Louisiana are unable to access critical healthcare services when needed and caregivers are hampered in providing care that is most appropriate. Though the healthcare landscape appears grim, the post-storm panorama presents an opportunity for change with potential for rebuilding and redesigning the healthcare sector.
Many Tulane faculty, resident physicians and alumni have became involved in discussions about redesigning health care in the area. While it is a long-term goal, Whelton says that he and his Tulane colleagues are fully committed to playing a leadership role in that redesign, which will include health professional training, healthcare delivery, promotion of wellness and the economic revitalization of the community, and training future healthcare leaders.
In July 2006, the Louisiana State Legislature formally named 40 members to the new Louisiana Health Care Redesign Collaborative with the charge of reshaping delivery of health care and medical services in the greater New Orleans area, particularly for the indigent and underinsured. Tulane leaders serving on the collaborative include Whelton, Alan Miller, recently named interim senior vice president for health sciences, and and a number of Tulane physicians and administrators.
In October 2006, the collaborative sent a proposed revamp of the New Orleans healthcare system to the U.S. Department of Health and Human Services.
The healthcare redesign plan called for doing away with the two-tiered system where indigent care was provided by Charity and adopting a plan to provide government-subsidized insurance to the nearly 127,000 people in the four-parish New Orleans area who are currently uninsured.
The plan would allow low-income citizens to access health care at a choice of settings. Any healthcare spending changes in Louisiana's care for the uninsured needs legislative approval in the state budget process. But the state also needs approval from the Department of Health and Human Services to change regulations on how the state can use federal money for health care.
An active contributor in the process to revamp health care has been Karen DeSalvo (M '92, PHTM '92), who trained on the Tulane service at Charity. She holds the C. Thorpe Ray Chair in Medicine and serves as chief of the section of general internal medicine and geriatrics at Tulane. DeSalvo has been a strong proponent of the "medical home" concept, which was embraced in the collaborative's plan. The focus of the medical homes--usually neighborhood-based clinics--will be on keeping people healthy, DeSalvo says, rather than providing more expensive care when they become acutely or chronically ill.
"Studies have shown that the more primary care in a community, the better health of the community," DeSalvo notes. As executive director of the Tulane Community Health Center at Covenant House, located on the edge of the French Quarter, DeSalvo considers the clinic to be a model of neighborhood-based health care for the city of New Orleans.
The center opened in the days following Hurricane Katrina as a source for tetanus shots for residents in the French Quarter, Treme neighborhood and downtown New Orleans.
Services expanded as demand increased. By the one-year anniversary of Katrina, more than 7,800 patients had sought care at the clinic. The center's services now include adult primary care, mental health counseling, geriatric care and health education.
The center is able to continue its work through supporting partnerships with 15 community groups. DeSalvo hopes to expand the center's services, including more examination rooms and a mobile health unit, with the Covenant House clinic becoming a model for other neighborhood clinics.
Thomas Farley (M '81, PHTM '91) also wants to see health care operate at street level. The U.S. Centers for Disease Control and Prevention tapped Farley, professor and chair of the Department of Community Health Sciences in the Tulane School of Public Health and Tropical Medicine, to participate in a planning group that released a report in November 2005 called "Framework for a Healthier Greater New Orleans." The report called for an emphasis on neighborhood clinics, health promotion and electronic medical records, also raising the question of whether or not Big Charity should be rebuilt. Farley also served on the Staying Healthy Workgroup of the Louisiana Health Care Redesign Collaborative.
"Studies have shown there is a limited number of clinical preventive services that have proven to be of benefit, including blood pressure screening, cholesterol screening, smoking cessation programs, mammograms and pap smears," says Farley who was in residency training on the Tulane service at Charity in the early '80s. "These services should be free, easily available and emphasized. This is where we see the greatest benefit--the simple things, always. People need to have a clinic nearby, but they don't need to have a hospital nearby."
With funding from the Robert Wood Johnson Foundation, Farley, director of the Prevention Research Center, now is concentrating his efforts on building healthy neighborhoods centered around clinics that promote wellness. DeSalvo concurs, stating that her vision of the future of health care is for more clinics in neighborhoods, so that patients can walk to their doctor's appointments instead of having to take public transportation. Access to caregivers is an important issue that the collaborative plan hopes to redress by the implementation of medical homes.
"Many patients who come to us in the emergency department come because they have limited or no access to other healthcare providers," says James Moises, a clinical assistant professor of surgery who is clerkship director for emergency medicine in the Tulane School of Medicine and co-director of the emergency department at Tulane University Hospital and Clinic. "It's not an insurance issue a lot of times--it's because patients have to wait two months or longer to see their primary care doctor, if they even have one."
The city needs about 100 additional primary-care physicians and between 15 to 30 new clinic sites to provide enough care to its citizens, says Richard Streiffer, professor and chair of the Tulane Department of Family and Community Medicine. Streiffer is currently on leave to assist the Louisiana Department of Health and Hospitals in rallying support for the redesigned healthcare plan, which must be vetted by the Louisiana state legislature when it convenes in April 2007.
"The plan is not an end; it's really the beginning," says Streiffer, who adds that Louisiana has clung to what is arguably the most archaic healthcare system in the nation. "This is an unprecedented opportunity to create a better system for the long-term. Connecting more patients with primary care services is a healthcare reform that is evidence-based and has been shown to improve the health of the population."
A central quandary with the redesigned healthcare plan is how it might be implemented--and at what expense. The collaborative estimated that the cost would amount to $366 million to implement the healthcare redesign plan in Orleans, Jefferson, St. Bernard and Plaquemines parishes by the fifth year. But less than a month after the collaborative issued the plan, the projected cost had mushroomed to more than $500 million annually once it is implemented.
Claudia Campbell, professor and chair of the Tulane Department of Health Systems Management in the School of Public Health and Tropical Medicine, volunteered to serve on the Louisiana Health Care Quality Forum, which is charged with developing clinical quality guidelines and reporting data on the performance of the medical homes.
A health economist interested in financial performance and access to care, Campbell believes designing appropriate evaluation tools to measure quality of care is integral to the success of the new healthcare system. She advocates transparency and making information public.
"I want to push for telling the community who is doing a good job and who isn't, so consumers have the necessary information to make good choices," Campbell says. "Quality and performance standards about the various healthcare choices should be available--are the medical homes, hospitals and other healthcare organizations doing a good job or not?"
Campbell adds that the implementation of health information technology, linking the medical homes and a network of healthcare providers using electronic medical records, will put Louisiana at the forefront of health care in the country.
"This will provide continuity of care and it will fuel quality of care," Campbell predicts. "A high quality of care can correlate with improved efficiency and lower cost of the healthcare system in the long run. No doubt it's going to cost more initially to provide better care to the citizens of this area. Our hope is that the healthcare system will be utilized more correctly, resulting in better care."
DeSalvo also advocates a system of electronic patient records, which, with patient consent, could be shared between clinics so that patients could go to a variety of locations and receive continued care. One positive outcome from Katrina, DeSalvo says, is the formation of an ambulatory healthcare network, a safety net of providers who are meeting the needs of the low-income population.
Electronic health records--an innovation since the storm--link the local clinics that are primarily operated by non-profit and faith-based organizations. Currently only about a quarter of healthcare providers in the United States use electronic medical records, according to a recent survey.
For decades, graduate medical education programs traditionally have taken place in hospital settings, not neighborhood clinics. But in a city with limited hospital facilities, everyone makes adjustments. While they wait for the Louisiana state legislature to deliberate the merits of the healthcare redesign, Tulane faculty are repositioning graduate medical education programs.
Ronald Amedee, associate dean for graduate medical education, has been concentrating on strengthening alliances with existing hospital partners and developing new training sites at community hospitals and community-based clinics. This academic year, Tulane voluntarily reduced the number of residency slots. A total of 365 residents and fellows were on board for training in the 42 Tulane medical and surgical post-graduate programs at 18 affiliated hospitals and facilities, Amedee says.
Before Hurricane Katrina, Tulane had a total of 46 training programs and there was a total of about 550 Tulane residents and fellows. "This is a much smaller attrition than predicted by the ACGME (Accreditation Council for Graduate Medical Education), which said we'd probably lose half of our trainees because of the disaster," says Amedee. "This year, we increased our standards--'quality over quantity' was our motto."
As for retention in the training programs after Katrina, Amedee commends the residency program directors for their hard work securing viable training sites for residents who had been training at Charity and other hospital-based programs. In the months after Katrina, Tulane continued to pay salaries, benefits and malpractice insurance for resident physicians who were dispatched to care for patients at 91 healthcare institutions across the country.
Jeffrey Wiese, director of the internal medicine residency program at Tulane, expanded his territory, personally visiting every displaced medical resident in his program at 50 institutions nationwide. According to Wiese, he logged 33,000 miles by car, 15,000-plus cell phone minutes, 1,534 gallons of gasoline, 197 gallons of coffee, and 95 nights of sleeping in a hotel for a total 1,155 hours of sleep while he worked nearly 3,600 hours to reach out to the displaced residents.
His efforts paid off, with 95 percent of the internal medicine residents returning to New Orleans for the 2006-07 academic year, while many others chose to come to Tulane for the first time. A member of the senior staff of the state health and human services department, Streiffer is facilitating work groups and focusing on bolstering graduate medical education. A past president of the Louisiana Academy of Family Physicians, Streiffer's vision centers on ways to enhance future primary care workforce development through graduate medical education in community settings, both clinics and physician practices.
"Graduate medical education is going to have to change," Streiffer asserts. "We have to sustain partnerships with community hospitals and train community faculty. Ambulatory sites are becoming more prominent, and this requires changes in how the government pays for training physicians at non-hospital sites."
Architect of the federally funded Tulane Rural Medical Education program, Streiffer created a network of family physicians throughout Louisiana and the Gulf Coast who serve as mentors to Tulane medical students as they rotate on family medicine clerkships. Streiffer hopes that graduate medical education programs similarly can grow in physicians' practices and clinics.
A native of Lafayette, La., Breaux came to New Orleans for medical school at Tulane, pursued all his medical training at Tulane except for two years in the Marine Corps, and has spent the rest of his life in New Orleans. Breaux, who worked on the Staying Healthy Workgroup of the collaborative, once had a busy private practice in New Orleans East and St. Bernard Parish, areas hit hard by Hurricane Katrina. After the storm, when his business dissolved, Breaux accepted a position with the growing Ochsner Medical Foundation system.
"I say it's time to rethink the Charity system of health care," Breaux says. "We need to redefine what is cost-effective. I strongly feel that the cost savings over time may not be in dollars and cents, but if we improve the quality of health, if people are living longer, healthier lives, it will be a worthwhile investment."
Breaux remains optimistic about the future of health care in Louisiana. "I think we need to focus on a new paradigm of quality health care for all of our citizens, with equal access," Breaux says.
Fran Simon is managing editor in the Office of University Publications.
Tulane University, New Orleans, LA 70118 504-865-5000 firstname.lastname@example.org