On Life Support
New Orleans's against-the-odds struggle to care for the infirm
NEW ORLEANS--Peter DeBlieux always pictured himself working in a tent one day. It just "wasn't in this country." A veteran emergency-room physician, DeBlieux is inside a tent pitched in an abandoned Lord & Taylor store just a few blocks from where he once ran one of the busiest ERs in the United States. That would be New Orleans's Charity Hospital, but, thanks to Hurricane Katrina, DeBlieux can't go back there. The flood that followed Katrina knocked out Charity's electricity and water. Patients and staff spent five grueling days trapped in the hospital in 100-degree heat, rationing drinking water, and hand-squeezing "ambu" bags to keep ventilator patients alive.
That was the easy part, some now say. Seven months later, New Orleans's healthcare system is floundering, and the fact that the city's once biggest hospital exists in a 30-bed tent is just one of the most obvious symptoms. When Charity started offering emergency care in a military tent on the convention center parking lot last September, DeBlieux thought he'd be practicing medicine this way for a month, tops. "Seven months out? It's not OK," he says. "This is the United States of America. This is not a Third World country."
Before the storm, greater New Orleans had 16 acute-care hospitals. Now there are nine, with just 2,000 of the 4,000 beds the city used to have. A year ago, there were about 63 nursing homes. Today, there are 34. Ninety clinics provided safety-net care; now there are 19. No one knows how many doctors and nurses remain in the Crescent City; thousands fled because their houses were ruined or their children's schools closed. Charity had the region's only Level 1 trauma center; the closest now is in Shreveport, 350 miles away. "Healthcare here remains unacceptably primitive," two New Orleans physicians wrote in last week's New England Journal of Medicine. "Without rapid, coordinated, and effective help from government agencies, we fear that disproportionate human suffering and death will continue to plague greater New Orleans."
The Big Easy, in fact, is trapped in a cruel vise. While the number of institutions offering medical care has shrunk drastically, the number of people seeking help has not. There are now about 1 million people in the New Orleans area, compared with 1.3 million before Katrina, and more arrive every day. Some are residents returning home. Others are workers drawn by high pay for reconstruction work. The nine hospitals are swamped. "We're jammed to the gills, our census is higher than it was prior to the storm, and we've had to open more beds with many fewer RNs and support services," says Nancy Davis, chief nursing officer for the Ochsner Health System, one of three hospitals in New Orleans that stayed open through Katrina. ER visits at Ochsner are up 60 percent, and the hospital is delivering twice as many babies as it did a year ago.
In the perverse logic of this disaster, hospitals like Ochsner that are making heroic efforts to tend to the sick and injured are losing millions of dollars a month. Some of that is because uninsured patients who formerly went to Charity now go to Ochsner and the few other hospitals still open. Before the storm, just 3 percent of these hospitals' patients had no insurance (half the national average of 6 percent). Now they are seeing 9, 12, or 20 percent uninsured. The number of patients with private health insurance, the cash cow for hospitals, has dropped, since many people have lost their jobs. At the same time, patients are staying in hospitals longer because there are few nursing homes to discharge them to, or family members don't have a home where they can care for them.
"Solace." And while revenue is down, costs are up--way up. The biggest expense is staff. With housing scarce and expensive, hospitals are paying premium wages for janitors, accountants, and kitchen workers. West Jefferson Medical Center, just across the Mississippi River in Marrero, is serving 20 percent more inpatients and 18 percent more outpatients than it did a year ago, with the same number of full-time staff. The hospital has had to hire travel nurses at double the cost of a staff nurse. "If we had more nurses," says Gary Muller, the hospital's CEO, "we could open more beds."
Tulane Hospital reopened its downtown building in February with about 60 of its 235 pre-Katrina beds. The hospital's organ-transplant program is back up and running. But space is tight. Says CEO Jim Montgomery: "We're having a real problem with patients stacking up in the ER waiting for beds."
The shortage of beds means not only long ER waits (box, Page 58) but also less room for other patients. "There's a challenge every day of not having beds open for elective surgery," says Mark Peters, CEO of East Jefferson General Hospital, a public nonprofit in New Orleans. But, he adds, "it's very difficult to think about adding beds if you're just going to lose more money."
The cash crisis has been exacerbated by Louisiana's unique method of providing indigent care. In other states, both public and private hospitals receive federal and state funds to help cover the cost of caring for the uninsured. But in Louisiana, almost all the $761 million flows to a state-run, 10-hospital system administered by Louisiana State University Healthcare Services Division. "Big Charity," which has been providing medical care to all comers since 1736, was the system's flagship. With 150,000 ER visits and 300,000 clinic visits a year, Charity drew patients from throughout the state, a critical source of care in a region where just over half the adults were insured through work. At least it was.
Today, most of the hospital's thousands of employees are scattered. Ben DeBoisblanc, for example, who ran Charity's intensive care units, is picking up shift work at other hospitals and living in his SUV. Big Charity and its sister hospital, University, are dark and empty, the only signs of life security guards watching TV and staff members who return to salvage medical equipment. Since September, the ER staff has wandered the ruined city like medical gypsies: to tents in a parking lot at the convention center; to the USS Comfort; to a parking lot near University Hospital; then inside the convention center, and, since March, in the defunct Lord & Taylor. Bare sheetrock covers the bottom 2 feet of the pink walls, marking the reach of Katrina's floodwaters. The 30 beds in the ER tent serve about 4,500 patients a month, about one third of its former volume. It's a patchwork operation; most lab tests have to be sent an hour away to Houma, and once patients are diagnosed, there are few options for follow-up in the city. The lack of a hospital, says ER physician Keith van Meter, has produced an odd form of medicine. Doctors, for example, order CT scans because they can't get blood tests and invent other workarounds. With no end in sight, frustration builds. "The joy of seeing patients is the only solace we have to comfort us."
Despite the limited care, patients are showing up with serious problems, including untreated hypertension, diabetes, bad staph and strep infections, and AIDS. "We diagnose new cancers easily three, four times a week here," says DeBlieux. In the days of Big Charity, cancer patients would be sent upstairs for chemotherapy and radiation; now patients are referred to state-run hospitals in Houma or in Baton Rouge, 90 minutes away. "Who do you think suffers?" asks DeBlieux.
Coming home. For many patients, visiting the tent ER, strange as it is, is like coming home. "I knew Charity was the best place to come," says Rosemary Allen. Katrina flooded her home in New Orleans, and she and her husband are now living in Houston. After two doctors there refused to see her, even though she said she would pay, Allen, 55, and her husband drove the 350 miles back to New Orleans so that she could see the Charity doctors about her diabetes and shoulder pain. Charity helped--to a point. "They tell me I have to go to Baton Rouge," Allen says, "for an ultrasound."
Slowly, the Charity ER is growing. Staffers are planning to shift the beds from the tent to cubicles in the Lord & Taylor, screened by purple plastic shower curtains. Next week, the hospital plans to open a 30-bed trauma center in space leased from Ochsner through the end of the year. By then, hospital administrators hope to have rehabilitated several units in nearby University Hospital with $13 million in FEMA funds. The Lord & Taylor ER will remain open.
Still, the venerable hospital's future remains uncertain. Before the storm, LSU officials planned to replace Charity's 1939 art deco building. In February, they inked an agreement with the flooded Veterans Administration hospital across the street to explore building a shared campus, which could open in five years if funding is available, says LSU's CEO Don Smithburg. Some local politicians and Charity employees say the hospital could be fixed up more cheaply and quickly. "Those very well intentioned folks who want to get back in there will work anywhere," Smithburg says, "but that doesn't mean it's the best for patients."
The LSU system still receives most of the state and federal funds for uninsured care because the money is attached to the hospitals. "We were hopeful that some of that money that had been going to pay for the poor and the uninsured could have been shifted to the private hospitals," says John Matessino, CEO of the Louisiana Hospital Association. Instead, the Legislature cut $136 million. In early April, the state started doling out $382 million in federal relief money to help pay for uncompensated care provided through January 31, with $114 million going to private hospitals. An additional $30 million is under consideration, but it's unclear when--or if--checks will be cut. "It's hard to say that you're not appreciative of any money at this point, but that package did not solve the problem," East Jefferson's Peters says. "The pats on the back don't cut it anymore."
Upgrade. East Jefferson and West Jefferson are both losing about $2.5 million a month, about 10 percent of their monthly revenues. Tulane lost $8.5 million in February alone. "We made the decision after the storm to take all comers, regardless of being able to pay," says Peters. "Our ability to do that isn't going to last much longer."
No one disputes that Louisiana's healthcare system needs an upgrade; Medicare ranks it as having the highest costs in the nation and the lowest quality. "One thing we're trying to do, quite honestly, is not just re-create the system the way it was in Louisiana before," says West Jefferson's Muller. "People couldn't get into the clinics; they weren't well run; they were costly."
But no one is pretending that a new system would be taking care of people anytime soon. In recent months, that realization has begun to strike the employees who have been working extra shifts at places like Ochsner. Nancy Davis has seen even her strongest and most capable employees lose heart. "Everyone kept thinking that we're going to turn the corner; it's going to get better," she says. "It's not."
This story appears in the April 24, 2006 print edition of U.S. News & World Report.