Feeling the pulse

Call it a side effect of the Baby Boomers going gray. Or blame it on financial pressures squeezing adults of all ages. Whatever the reason, more and more people in the U.S. are worrying about health care. They fret about whether they’ll be able to get quality care when they need it. They stew over how they’ll pay for it when the need is most acute.

Fears about the future of health care increasingly drive major life choices. The availability of health insurance as part of an employment package can be the tilting point in a job decision. The proximity of good hospitals, quality child care or assisted living options can sway an individual’s or a business’s relocation plan.

In a nation beset with health care challenges, Louisiana is something of a microcosm. Like the country at large, we face big problems: rapidly rising medical costs, difficulties in assuring equal access to care for all citizens and deteriorating health status in some important categories. The state’s population is aging and the ranks of its uninsured have grown.

In some respects, though, conditions in Louisiana are more dire than in other states. Louisiana houses a disproportionately large number of impoverished citizens who have spotty access to care and no private health insurance coverage. The state’s high levels of poverty contribute to higher incidences of serious and chronic diseases, driving up medical costs for the overall population. Most critical of all at the moment, the health care system of the state’s largest metropolitan area remains crippled by the hurricanes of 2005.

Poor Track Record
Even before Hurricanes Katrina and Rita hit southern Louisiana, the state’s overall health care picture was blotchy. The number of citizens living without health insurance had spiraled past 600,000. Because so few had access to outpatient clinics or coverage to pay for it, outpatient visits in hospital settings were 18 percent higher in Louisiana than in the nation at large. The state averaged 43 percent more emergency department visits per 1,000 population than the rest of the country.

All in all, according to 2003 study of Medicare quality and spending, Louisiana spent the most money per beneficiary but finished last among the states in an overall quality ranking. The hurricanes helped push the state still closer to a health care breaking point. The catastrophic flood that followed Katrina put five of New Orleans’ nine full-service hospitals out of business. Today, staffing problems still plague the facilities that are open.

“In terms of primary care, we’ve had great difficulty just meeting the needs of the population,” Dr. Fred Cerise told lawmakers in Washington, D.C., nearly two years after the flood. Cerise, who is secretary of the Louisiana Department of Health and Hospitals, noted that addressing mental health issues is one of the biggest challenges the area currently faces. Inpatient and emergency crisis psychiatric facilities were destroyed during Katrina, and many mental health professionals who left the area have not returned.

New Game Plan

Deep concern for the health status of south Louisiana citizens prompted a surge of creative thought about reforming health care throughout the state. Last year, U.S. Health and Human Services Secretary Michael Leavitt called for the state to move away from a Charity Hospital System model for treating the uninsured in favor of government-subsidized health insurance for some low-income people.

In response, state officials and health leaders formed a group called the Louisiana Health Care Redesign Collaborative with the aim of designing a new care model that could serve not just the state, but perhaps the entire country.

“We have looked hard at what’s needed to improve overall operations of the health care delivery system,” says Cerise. “In this country we spend twice as much per capita on health care as any of our peer countries spend, but we don’t have measurably different outcomes for that spending. We are trying to look at how to get better outcomes for the dollars that we’re spending.”

In 2006, the collaborative set about drawing a blueprint for rebuilding health care in hurricane-affected areas that eventually could become the basis for a revamped system statewide.

“Much of the work has focused around making the health care system less fragmented, more coordinated and more patient-centered,” says Cerise.

Information Flow
A crucial component of health care reform is opening the taps on medical information so that records and data can flow quickly in many directions. Bringing America’s health care system fully into the electronic age is vital to improving the efficiency and effectiveness of treatment, yet progress on this initiative still lags.

“If we’re going to have better coordinated care, information has got to flow better,” says Cerise.

Much of the nation’s health care system still relies on a “paper system.” A patient’s medical records consist of paper documents that reside in one or more doctors’ offices and don’t move readily with the patient.

In the months after the hurricanes, many in Louisiana witnessed the problems this creates. With many medical records destroyed, and with both patients and their doctors scattered around the country, patients found it difficult to get quick access to medications or treatments that were important in managing existing illnesses.

Even under normal conditions, clogs in the information pipeline have costly and detrimental effects. Say, for instance, that an individual’s primary doctor suggests he or she see a specialist. An appointment is made, the patient visits the specialist and the specialist, who doesn’t have access to the patient’s complete record, orders new tests or procedures to get information that may already have been gleaned by another physician.

“Redundant testing occurs frequently because critical information is not available at the time of a visit,” Cerise says. This is particularly costly, not to mention potentially life-threatening, in emergency situations.

Cerise says that Louisiana is working to expand its Medicaid program to increase coverage of the uninsured, using federal grants made available for disaster relief. In doing so, the state also hopes to launch community-wide health information exchanges – programs that make medical information available from a central point regardless of where a patient enters the health care system.

In addition, the state has formed the Louisiana Health Care Quality Forum, an independent nonprofit entity whose mission is to identify areas where quality of care appears to be falling short. An example might be evidence that the incidence of cancer has increased in a certain parish because screening for the disease is inadequate or unavailable.

“The goal is to improve health care by providing every citizen with a medical ‘home’ that’s prevention-centered, neighborhood-located and electronically connected. Success will mean that Louisiana and New Orleans will have health care systems that can serve as models for the nation,” Cerise says.

Bricks and Mortar

Cerise and other leaders supporting these efforts received encouraging news recently when the U.S. Veterans Administration (VA) announced where it intends to build a replacement for its hurricane-damaged local hospital. The VA said on Aug. 21 that downtown New Orleans is its preferred site.

The VA facility represents an economic linchpin of another proposal, by Louisiana State University (LSU) Health Sciences Center, to develop a 480-bed teaching and research hospital in the city.

Shortly after the Katrina flood knocked the all-important Charity Hospital out of commission, LSU proposed a new medical complex to be funded in part by federal relief money. The hospital would serve the medical needs of both private-pay and uninsured patients and at the same time provide a teaching ground and research campus for both LSU’s and Tulane University’s medical schools, just as Charity Hospital had done in the past.

LSU proposed teaming up with the VA, building the two new hospitals side-by-side in the city and sharing certain services and facilities in order to make both hospitals more economically viable.

The proposal gained momentum after the state Legislature agreed to fund preliminary planning work. But later Jefferson Parish-based Ochsner Medical Foundation mounted a competing effort to draw the new VA hospital to an available site next to Ochsner.

LSU Health Sciences Chancellor Larry Hollier cheered the results of the VA’s deliberation, pointing out that putting both hospitals on a downtown campus will create a critical mass of investment that will help New Orleans become a center of bioscience research and potentially lucrative clinical trials.

“For New Orleans, this is obviously a boon because it will be the anchor that helps us build a major medical center,” Hollier said.

He predicted the combined projects will generate $1.5 billion a year in new local spending. Hollier said the construction phase will create some 6,000 jobs. “And down the line we’re talking about 10,000 jobs to support all this activity,” he said.
Until a mandatory environmental impact study is completed on both the downtown and the Jefferson Parish sites, a final decision by the VA is pending. If the study reveals no reasons why the new hospital should not be built in New Orleans, the new facility could open in about five years, officials say.

Building Medical ‘Homes’

Let’s say you’ve been bothered by persistent itchy eyes and a scratchy throat, so you schedule an appointment with a doctor to check it out. When you sign in at the physician’s office, the staff taps into an electronic record containing your medical history and an alert pops up to show that you are not up to date with certain important cancer screenings. So the staff explains how and where you can go about getting the appropriate tests.

That’s the type of scenario the Louisiana Health Care Redesign Collaborative envisioned when they recommended that the state develop a “medical home” concept of care. A key part of the state’s plan for improving the delivery of care to all residents is improving coordination among all the potential care providers, from primary care doctors and general hospitals to specialty clinics, emergency rooms and surgery centers. The medical “home” is not really a physical structure, but rather an electronic network that enables providers to access medical information from a centralized source.

“We’ve begun a pilot program in the New Orleans area to better coordinate care by developing electronic records, with referral relationships with hospitals, so information flows readily back and forth,” says Dr. Fred Cerise, secretary of Louisiana Department of Health and Hospitals.

Recently, DHH landed a $100 million federal grant that will support development of the medical home concept as well as expansion of primary care in the New Orleans area. The money will help existing community clinics add services (including medical and mental health care, substance abuse treatment, oral health care and optometric health care), open satellite clinics, stay open longer hours and hire more medical staff. Designed to serve Medicaid recipients and uninsured citizens, this primary care system will link neighborhood clinics electronically.

Eventually, Cerise hopes the program will expand statewide. But he says developing a larger information network will require the cooperation and support of a great many entities, as well as a significant political commitment to change the status quo.
“It’s saying that we need a strong primary care focus, and we need to pay primary care doctors appropriately, to do patient education and to implement electronic records – these are things that we know will result in better utilization of services,” he says.

Change Won’t Be Easy
What can Louisiana citizens expect from their health care systems during the next 10 to 20 years? Much depends on the implementation of policies at both the federal and state levels. Health care will be a key issue in the 2008 presidential election, as well as in the upcoming Louisiana gubernatorial election. The candidates are sure to refine their positions on access and payment plans in the months to come.
Meanwhile, Dr. Fred Cerise, secretary of the Louisiana Department of Health and Hospitals, has put improved communication systems among patients and providers of care at the top of his wish list.

“We’re hoping to see more advances in patient care, such that you may be able to access the health care system without having to rely on actual visits to a doctor’s office,” he says.

The vision is one of patients communicating with doctors or other health professionals via e-mail or telephone and resolving many minor or non-life-threatening problems without racking up the cost of an in-person visit. Patients might, for instance, be able to consult with a nurse practitioner or health education specialist who could respond appropriately and avoid unnecessary time and testing that an office visit might trigger.

Physicians, too, would be better able to communicate with one another. Or primary care doctors could quickly consult with specialists by e-mail or phone, again possibly eliminating the need for separate visits by the patient to different doctors.

“Certainly, patients would see doctors where necessary, but we all know there’s a lot more savings that can be built in if we have better information and better coordination of doctor visits,” Cerise says.

He warns, however, that fundamental systems changes will require changing the way providers are reimbursed for services, and that won’t be simple. “Big changes will be needed if we are to evolve into a more patient–centered health care system,” he says. –K.F.

Louisiana health care facts
In July 2007, James Richardson, Alumni Professor of Economics at Louisiana State University, reported on the impact of the health care industry on the state’s economy. Richardson’s study, commissioned by the Louisiana Hospital Association, reported these facts for 2004:

•  Louisiana’s health care sector employed almost 260,000 persons, with a combined payroll of $7.6 billion.

•  Health care accounts for almost 16 percent of total payroll in the state.

•  The state’s 233 hospitals employed 102,000 people.

•  The New Orleans metropolitan area represents about 30 percent of total hospital employees in the state, followed by:
– 34 rural parishes representing a combined 19 percent;
– Baton Rouge, 15 percent;
– Shreveport, 11 percent;
– Lafayette, 7.5 percent;
– Alexandria, 5 percent;
– Monroe, 4.8 percent;
– Lake Charles, 4.5 percent; and
– Houma-Thibodaux, 3.4 percent.