Two years after Hurricane Katrina's floodwaters submerged much of New Orleans, the city's relatively few open health care facilities and diminished corps of physicians are struggling to serve a smaller, but very needy, population.

It's a picture that's changed somebut not muchsince a year ago.

Emergency departments, in particular, are bearing the brunt of the broken system, as they are one resource that is nearly always available to the uninsured and those with little access to primary care.

It is thought that about 200,000 people now reside in the city, with another 400,000 in the three surrounding parishes (Jefferson, Plaquemines, and St. Bernard). In that region, there are some 101,000 uninsured residents and 147,000 Medicaid recipients, according to the Louisiana Department of Health and Hospitals (DHH).

It's still unclear how many of the approximately 3,000 physicians who practiced in the area before the storm have returned. In mid-2006, according to claims information from Blue Cross and Blue Shield, only half had come back. The Louisiana State Board of Medical Examiners said that from August 2005 to July 2006, the number of primary care physicians declined from 2,645 to 1,913.

The lack of access to care has hit hard. According to an analysis of death notices in the Times-Picayune by the Dr. Kevin U. Stephens Sr., director of the city health department, and colleagues, there was a 47% increase in the mortality rate in the first 6 months of 2006to 91/100,000, compared with 62/100,000 seen in 2002-2004 (Disaster Med. Public Health Preparedness 2007;1:15-20). The authors said that they studied death notices because of vast gaps in state and city data.

Primary Clinics to Be Medical Homes

According to Dr. Frederick P. Cerise, secretary of the Louisiana Department of Health and Hospitals, there are 26 primary health care sites in the New Orleans area, including federally qualified health centers, Tulane University and Louisiana State University outpatient clinics, and mobile and nonprofit clinics.

The sites will receive $100 million from the federal government over the next 3 years, said Dr. Cerise in an interview, as part of a $161 million allocation aimed at improving health care in the area.

The clinics are eagerly awaiting the shot in the arm, said Dr. Karen DeSalvo, executive director of Tulane University Community Health Center at Covenant House. The Tulane clinic is part of an 18-clinic alliance, the Partnership for Access to Healthcare (PATH).

The money is "going to give us a chance to expand upon what's been developingmultiple neighborhood clinics that are turning into medical homes," said Dr. DeSalvo, who also is chief of general internal medicine and geriatrics at the university and special assistant to its president for health policy.

All PATH clinics have agreed to uphold and advance the principles of a medical home, she said. The concept was developed by the American Academy of Pediatrics and is being promoted on a national level by the American College of Physicians and the American Academy of Family Physicians.

Dr. DeSalvo said that while she believes the primary care picture is vastly improving in the city, noting that the 18 clinics see about 900 patients a day, too many patients still seek routine care from the emergency departments. "We're trying to find those patients in the ER and get them into our system," she said.

Inpatient Capacity Still Down

Currently, in New Orleans proper, there are five hospitals open; five more are either abandoned or closed, according to the Louisiana Hospital Association.

Louisiana State University, Baton Rouge, is once again operating a level one trauma center in downtown New Orleans at the LSU Interim Hospital (formerly University Hospital).

The now-179-bed Interim Hospital and Tulane Hospital are all that's left of the Medical Center of Louisiana at New Orleans. Before Katrina, that campus also included Charity Hospital, a Veterans Affairs (VA) hospital, and medical office buildings. LSU was able to open Interim Hospital with $64 million in Federal Emergency Management Agency (FEMA) funds. It has recently added a 20-bed detox unit (only 5 were staffed as of press time) and is in the midst of adding 33 inpatient mental health beds elsewhere in the city, as well as a mental health unit in the emergency department.

LSU is one of the main backers of a huge new medical campus within a few blocks of Charity Hospital on a 37-acre partly undeveloped parcel that the city has said it will take.

According to testimony by Mayor C. Ray Nagin at a field hearing of the U.S. House Committee on Veterans' Affairs in early July, the new campus would include 30 public, private, and nonprofit organizations, including LSU, Tulane, Xavier University, Delgado Community College, the LSU and Tulane hospitals, medical offices, and biotechnology companies. The state has put aside $38 million to fund a cancer research institute at the site. The cityalong with LSU and Tulaneis trying to convince the VA to rebuild on the campus.

Dr. Michael Kaiser, acting chief medical officer of the LSU Health Care Services Division, said at the field hearing thatbefore Katrinathe VA bought at least $3 million in services from LSU annually. Before Katrina, 75 Tulane physicians had joint VA-Tulane appointments, and 120 Tulane residents received training at the VA, said Dr. Alan Miller, interim senior vice president for health sciences at Tulane, at the hearing. Currently, 40 Tulane doctors provide services and training at VA outpatient clinics, which represents $2.2 million in physician compensation, he said.

The private Ochsner Health System is vying to have the new VA hospital built across the street from its campus in Jefferson Parish. At the field hearing, Dr. Patrick J. Quinlan, Ochsner's CEO, noted that the site "is above sea level and not located in a floodplain."

Because the federal government has not agreed to fund a new campus, Gov. Kathleen Blanco signed an executive order allocating an immediate $74.5 million for land acquisition and planning. To come up with the additional $1.2 billion needed, the state will float a series of bonds.

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Mayor C. Ray Nagin is supporting a plan for a new medical center on a 37-acre parcel a few blocks from Charity Hospital. Jay Westcott/Elsevier Global Medical News

Federal Incentive Grants Offered to Draw Physicians to Louisiana

The state of Louisiana and city of New Orleans are struggling to lure physicians, dentists, mental health professionals, and nurses back to the city, or at least to convince those who did return to stay in the face of an onslaught of uninsured patients and a patchwork system of care.

After Katrina, thousands of residents, many of them doctors and nurses, evacuated. A recent study, citing Louisiana State Board of Medical Examiners data, reported that the number of board-certified primary care physicians in New Orleans dropped from 2,645 in August 2005 to 1,913 in July 2006 (Disaster Med. Public Health Preparedness 2007;1:21-6).

In April 2006, the federal government declared the greater New Orleans area a health professional shortage area, eligible for federal grants to retain or recruit health professionals. This gave rise to the Greater New Orleans Health Service Corps.

The Louisiana Department of Health and Hospitals, which is overseeing the Corps, has received $50 million to spend on recruitment and retention; the money was originally earmarked at 70% for recruitment and 30% for retention.

Realizing how difficult it is keep physicians in the city, the state received permission to adjust the split, said Gayla Strahan, a program administrator for the DHH's Bureau of Primary Care and Rural Health and manager of the Service Corps effort. Now, half goes for recruitment and half for retention.

When the state applied for federal health shortage funds in mid-2006, there were 405 primary care physicians and 30 psychiatrists in the region, but just 76 primary care doctors and 6 psychiatrists at that time took Medicaid or uninsured patients. The DHH determined thatbased on the region's population at that time (about 700,000) and the Medicaid enrollment (about 135,000)there was a need for 48 more primary care physicians, 38 more dentists, 10 more psychiatrists, and 33 other mental health professionals, such as psychologists, licensed clinical social workers, and marriage and family therapists.

The department also will seek to retain and recruit faculty at the area's medical, nursing and allied health schools, said Ms. Strahan. The goal is to retain 50 primary care physicians and recruit 48 new ones by September 2009 when the grant cycle ends. For mental health, the goal is 24 retentions and 43 recruits; for dentists, it is 10 and 30, and for faculty, the aim is to keep 48 current positions and bring in 46 new appointments, including 24 at the medical schools.

The Service Corps also has earmarked a little over $2 million to retain 5 specialists and bring in 15 new ones. The bar is a little higher for a specialistthe applicant has to show there is a dire need. For instance, if there's only one cardiologist who agrees to accept Medicaid patients, "that's a dire need," said Ms. Strahan. Applicantsand there had been 300 as of press timehave to accept Medicare, Medicaid, and the uninsured; must work at least 32 hours a week in clinical practice; and have to be licensed in Louisiana or at least agree to become licensed before starting work. Once accepted, participants have a 3-year obligation.

Physicians, psychiatrists, and dentists can tailor their packages of incentives up to $110,000, which is paid in one lump sum at the beginning of the 3 years. They can use it toward salary, to repay loans, for malpractice premiums, and/or to buy health information technology. Mid-level providers are eligible up to $55,000, registered nurses and nurse faculty up to $40,000, and allied health professionals can receive $10,000 to $40,000, depending on the discipline.

For more information on the program and to download an application, visit

www.pcrh.dhh.louisiana.gov

New Orleans Health Care System Slow to Recover