Katrina's legacy: Moving beyond the storm
■ Five years after the hurricane devastated New Orleans' health system, the city's medical landscape has been transformed.
Charity Hospital still stands like a colossus amid the medical district in New Orleans, the city's tallest hospital at 289 feet. When the building opened in 1939, it was the country's second-largest hospital with 2,680 beds. Generations of physicians trained in the art deco building and Level I trauma center.
Until Hurricane Katrina struck five years ago, nearly all of New Orleans' uninsured patients were treated there or at Charity clinics in the surrounding blocks.
Immediately after the storm hit on Aug. 29, 2005, the hospital was fine.
"Then the levees broke, and the water started rising," said internist Cathi Fontenot, MD, who was the hospital's medical director when Katrina struck. "It flooded the basements where the backup generators were. Once the basements filled up, the electrical switch gears blew, and that's when we were in trouble."
It took five days to evacuate Charity Hospital, which has been closed ever since -- fenced in by barbed wire.
A spring 2006 survey of New Orleans physicians found that 25% still had not returned, according to results published in the July 2007 Disaster Medicine and Public Health Preparedness. New Orleans-based Tulane University School of Medicine laid off a third of its faculty, and the LSU School of Medicine laid off a quarter of the faculty at its New Orleans and Baton Rouge, La., campuses.
"Katrina destroyed everything I had built," said Floyd A. Buras, MD, a pediatrician who returned a month after the storm to find his small group practice in New Orleans' hard-hit Gentilly neighborhood a total flood loss. "Conceptually, you can relate to a building burning down or something. But this was more than that. It's like you woke up one morning and there were no people. The relationship I had built with 15,000 people disintegrated in one day."
The latest U.S. Census Bureau estimate is that more than 350,000 people live in the city -- about 80% of the pre-storm population. In 2008, the most recent data available from the Louisiana State Board of Medical Examiners showed the 3,681 licensed physicians in the Greater New Orleans' two largest parishes -- Jefferson and Orleans -- accounted for 84% of the pre-storm total. Dr. Buras, for one, re-established his practice in Metairie, La., a New Orleans suburb in Jefferson Parish.
After talk of closing LSU's New Orleans campus, the school is operating again in the city. Both the school and Tulane report that their medical school enrollments are higher than pre-Katrina levels. They have begun hiring clinical faculty again, and Tulane and LSU officials hope a proposed medical center complex will give the next generation of physicians a top-notch place to train.
Meanwhile, nearly three-quarters of the area's hospitals are open again. The Government Accountability Office concluded as early as September 2006 that the area had more staffed beds per 1,000 residents than the national average.
The physician decision
The recovery of New Orleans' health care system is by no means complete and was no sure thing. Individual physicians often faced gut-wrenching decisions about whether to return.
Pre-Katrina, Prateek Adhikari, MD, was an emergency physician at the now-shuttered Pendleton Memorial Methodist Hospital. When the storm hit, he and his wife, a nurse anesthetist, were childless. That made it easier to return to New Orleans weeks after fleeing to Tennessee. Today, they have an infant son to consider.
"I'm not sure what we would have done if we'd had a kid then," Dr. Adhikari said between sips of coffee he brewed in the ED break room of Tulane Medical Center, where he is chief of emergency medicine.
For some physicians, the disaster proved too much to bear.
Bong Mui, MD, came to the New Orleans area after leaving Vietnam in the 1970s. He was a family physician in Chalmette, a suburb in St. Bernard Parish that was badly flooded. As chief of staff at the now-demolished Chalmette Medical Center, he worked through the storm while his wife traveled to Houston to stay with family.
Katrina destroyed Dr. Mui's solo practice, the family's home and his wife's day spa business, all in Chalmette.
The devastation was the family's second major trial. Dr. Mui was studying in the United States when South Vietnam fell, leaving him separated from his wife and daughter for six years. During the days following Katrina, they found themselves separated again.
"We lost contact for two days, and she didn't know what happened to me," Dr. Mui said. "She didn't know whether I had drowned or not."
Though Dr. Mui loved Chalmette and caring for his patients there, Katrina gave his family an unwelcome flashback to its earlier ordeal.
"That experience really made me determined to not want to go through another disaster," Dr. Mui said. He has settled in Houston, where he is back in family practice, seeing 35 to 50 patients a day.
Other doctors stayed in the area but moved their practices out of New Orleans.
Some crossed one of the longest bridges in the world, measuring nearly 24 miles and stretching across Lake Pontchartrain, and relocated to the Northshore area. It's home to towns such as Slidell and Covington and has a wooded, suburban feel a world away from the densely packed streets of the city's French Quarter.
The Northshore served as a lifeline for Michael K. Hill, MD, after Katrina. The storm shut the multispecialty group practice he headed in the New Orleans East area, which took on eight feet of floodwater.
"Our service area was gone, our offices were gone and our physicians were scattered to the wind," said Dr. Hill, an infectious diseases specialist.
Just four of the practice's 27 physicians stuck together to see patients on the Northshore, where the group had a satellite office. The now-six-doctor practice opened a facility last December in a commercial subdivision in Covington. The paint on the wall still smells fresh.
"I didn't know whether I was going to stay here," Dr. Hill said. "I didn't know what the future of this area was."
He commuted an hour from his home in Metairie for the first few months of 2006 before deciding to sell the house and move to the Northshore for good. He sees some protection from the next storm in the choice, as do many New Orleanians who have moved above Lake Pontchartrain. "You don't have levees, and you're above sea level here," Dr. Hill said. "That's the main difference."
There are true die-hards who would never dream of leaving New Orleans. One is Brobson Lutz, MD, an internist and infectious diseases specialist who served as director of the New Orleans Dept. of Health from 1983 to 1995.
"My partner and I are just as busy now as we were before the storm," said Dr. Lutz, who lives in the French Quarter, which did not flood.
He isn't scared of another hurricane.
"I'm going to stay here 'til they haul me out," he said. "If we do get totally flooded, I'm just going to buy a houseboat and anchor it to my office."
As individual doctors struggled with how and whether to rebuild their practices, New Orleans wrestled with how to overcome Charity's closing. Among the city's uninsured and Medicaid patients, a culture of using the emergency department to access basic care was well-established, physicians say. The state ranked fourth nationwide in the rate of emergency department use, with 548 visits per 1,000 residents. Charity's 150 ambulatory clinics handled 350,000 outpatient visits a year.
The way medical care is delivered to the city's indigent patients -- most of whom are working poor and black -- has changed dramatically since Katrina.
"It's not even recognizable," said Karen B. DeSalvo, MD, MPH, chair of internal medicine and vice dean of community affairs and health policy at Tulane. "Prior to Katrina, it was highly centralized financially and geographically. It was a model of care that was heavily dependent on trainees for services, and as a result was not at all flexible in the face of disaster. We had all of our eggs in one basket."
After the storm, Dr. DeSalvo helped establish street clinics to provide primary care. She is now CEO of Tulane Community Health Centers, six clinics that deliver care to uninsured patients in their neighborhoods.
All the clinics are recognized by the National Committee for Quality Assurance as patient-centered medical homes, providing comprehensive primary care with the help of health information technology, social workers and physician extenders. Among the services is a mobile medical unit, a recreational vehicle bathed in Tulane green that travels to still-underserved neighborhoods such as Gentilly and New Orleans East.
More than 90 neighborhood clinics run by 25 organizations have delivered care to about a fifth of the area's patients -- the vast majority uninsured -- handling nearly 100,000 visits a year, according to the Louisiana Public Health Institute. Patients pay on an income-based sliding scale.
A January Commonwealth Fund survey of clinic patients found that they were less likely than participants in a national survey of adult patients to have medical bill problems. They also were much more confident in their ability to get safe, high-quality care when needed.
Most of the clinics, new or expanded since Katrina, have sprung up with help from the three-year, $100 million federal Primary Care and Access Stabilization Grant, which is set to expire Sept. 30.
The Louisiana Public Health Institute and others are hoping for a Medicaid waiver to extend the grant, but no such waiver had been announced as of this article's deadline.
Daughters of Charity Services of New Orleans, owned by the Catholic nonprofit Ascension Health system, has received nearly $8 million in federal grant money.
The organization runs seven mobile and brick-and-mortar clinics -- all NCQA-certified medical homes -- including a new, 30,000-square-foot facility in the Carrollton neighborhood that will offer primary care, dental care and badly needed mental health services.
Without adequate funding, uninsured patients will lose access to quality primary care services, said Robert M. Post, MD, medical director of the Daughters of Charity Health Centers. That's because there will be a gap between when the federal grant expires and when health system reform's expanded Medicaid eligibility takes effect in 2014.
"If there's no sustainability, or we don't come up with some interim plan, it will all be for naught," said Dr. Post, a family physician who moved to New Orleans from Chicago in 1993.
Tulane's Dr. DeSalvo, who chairs the 14-organization safety-net provider coalition 504HealthNet, said the effort to change how primary care is delivered to indigent patients cannot fade away. For all its devastation, Katrina presented a rare opportunity to dramatically improve care in New Orleans.
"I thought, 'We have a chance to rebuild better,' " she said. "I know it can be done, and we can do it sort of one clinic at a time. ... Everyone deserves this kind of care."
In the link, read about how dealing with Hurricane Katrina has led to changes in medical disaster planning.