Hurricane Katrina
Federal Grants Have Helped Health Care Organizations Provide Primary Care, but Sustaining Services Will Be a Challenge Gao ID: GAO-10-273T December 3, 2009The greater New Orleans area--Jefferson, Orleans, Plaquemines, and St. Bernard parishes--continues to face challenges in restoring health care services disrupted by Hurricane Katrina which made landfall in August 2005. In 2007, the Department of Health and Human Services (HHS) awarded the $100 million Primary Care Access and Stabilization Grant (PCASG) to Louisiana to help restore primary care services to the low-income population. Louisiana gave PCASG funds to 25 outpatient provider organizations in the greater New Orleans area. GAO was asked to testify on (1) how PCASG fund recipients used the PCASG funds, (2) how recipients used and benefited from other federal hurricane relief funds, and (3) challenges recipients faced and recipients' plans for sustaining services after PCASG funds are no longer available. This statement is based on a recent GAO report, Hurricane Katrina: Federal Grants Have Helped Health Care Organizations Provide Primary Care, but Challenges Remain (GAO-09-588), other GAO work, and updated information on services, funding, and sustainability plans, which we shared with HHS officials. For the report, GAO analyzed responses to an October 2008 survey sent to all 25 PCASG fund recipients, to which 23 responded, and analyzed information related to other federal funds received by PCASG fund recipients. GAO also interviewed HHS and Louisiana Department of Health and Hospitals officials and other experts.
PCASG fund recipients reported in 2008 that they used PCASG funds to hire or retain health care providers and other staff, add primary care services, and open new sites. For example, 20 of the 23 recipients that responded to the GAO survey reported using PCASG funds to hire health care providers, and 17 reported using PCASG funds to retain health care providers. In addition, most of the recipients reported that they used PCASG funds to add primary care services and to add or renovate sites. Recipients also reported that the grant requirements and funding helped them improve service delivery and expand access to care in underserved neighborhoods. As of September 2009, recipients used PCASG funds to support services for almost 252,000 patients, who had over 1 million interactions with a health care provider. Other federal hurricane relief funds helped PCASG fund recipients pay staff, purchase equipment, and expand mental health services to help restore primary care. According to data from the Louisiana Department of Health and Hospitals, 11 recipients received HHS Social Services Block Grant (SSBG) supplemental funds designated by Louisiana for primary care, and 2 received SSBG supplemental funds designated by Louisiana specifically for mental health care. The funds designated for primary care were used to pay staff and purchase equipment, and the funds designated for mental health care were used to provide a range of services including crisis intervention and substance abuse prevention and treatment. Most of the PCASG fund recipients benefited from the Professional Workforce Supply Grant incentives. These recipients hired or retained 69 health care providers who received incentives totaling over $4 million to work in the greater New Orleans area. PCASG fund recipients face multiple challenges and have various plans for sustainability. Recipients face significant challenges in hiring and retaining staff, as well as in referring patients outside of their organizations, and these challenges have grown since Hurricane Katrina. For example, 20 of 23 recipients that responded to the 2008 GAO survey reported hiring health care providers was a great or moderate challenge, and over three-quarters of these 20 recipients reported that this challenge had grown since Hurricane Katrina. PCASG fund recipients also reported challenges in referring patients outside their organization for mental health, dental, and specialty care services. Although all PCASG fund recipients have completed or planned actions to increase their ability to be sustainable, recipients are concerned about what will happen when PCASG funds are no longer available. Officials of the Louisiana Public Health Institute, which administers the PCASG locally, expect that some recipients might have to close and others could be forced to scale back capacity by as much as 30 or 40 percent. They have suggested strategies to decrease what they estimate would be a $30 million gap in annual revenues when PCASG funds are no longer available. With the availability of PCASG funds scheduled to end in less than 10 months, preventing disruptions in the delivery of primary care services could depend on quickly identifying and implementing workable sustainability strategies.
GAO-10-273T, Hurricane Katrina: Federal Grants Have Helped Health Care Organizations Provide Primary Care, but Sustaining Services Will Be a Challenge
This is the accessible text file for GAO report number GAO-10-273T
entitled 'Hurricane Katrina: Federal Grants Have Helped Health Care
Organizations Provide Primary Care, but Sustaining Services Will Be a
Challenge' which was released on December 3, 2009.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Testimony:
Before the Committee on Oversight and Government Reform, U.S. House of
Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 10:00 a.m. EST:
Thursday, December 3, 2009:
Hurricane Katrina:
Federal Grants Have Helped Health Care Organizations Provide Primary
Care, but Sustaining Services Will Be a Challenge:
Statement of Cynthia A. Bascetta:
Director, Health Care:
GAO-10-273T:
GAO Highlights:
Highlights of GAO-10-273T, a testimony before the Committee on
Oversight and Government Reform, House of Representatives.
Why GAO Did This Study:
The greater New Orleans area”Jefferson, Orleans, Plaquemines, and St.
Bernard parishes”continues to face challenges in restoring health care
services disrupted by Hurricane Katrina which made landfall in August
2005. In 2007, the Department of Health and Human Services (HHS)
awarded the $100 million Primary Care Access and Stabilization Grant
(PCASG) to Louisiana to help restore primary care services to the low-
income population. Louisiana gave PCASG funds to 25 outpatient provider
organizations in the greater New Orleans area. GAO was asked to testify
on (1) how PCASG fund recipients used the PCASG funds, (2) how
recipients used and benefited from other federal hurricane relief
funds, and (3) challenges recipients faced and recipients‘ plans for
sustaining services after PCASG funds are no longer available.
This statement is based on a recent GAO report, Hurricane Katrina:
Federal Grants Have Helped Health Care Organizations Provide Primary
Care, but Challenges Remain (GAO-09-588), other GAO work, and updated
information on services, funding, and sustainability plans, which we
shared with HHS officials. For the report, GAO analyzed responses to an
October 2008 survey sent to all 25 PCASG fund recipients, to which 23
responded, and analyzed information related to other federal funds
received by PCASG fund recipients. GAO also interviewed HHS and
Louisiana Department of Health and Hospitals officials and other
experts.
What GAO Found:
PCASG fund recipients reported in 2008 that they used PCASG funds to
hire or retain health care providers and other staff, add primary care
services, and open new sites. For example, 20 of the 23 recipients that
responded to the GAO survey reported using PCASG funds to hire health
care providers, and 17 reported using PCASG funds to retain health care
providers. In addition, most of the recipients reported that they used
PCASG funds to add primary care services and to add or renovate sites.
Recipients also reported that the grant requirements and funding helped
them improve service delivery and expand access to care in underserved
neighborhoods. As of September 2009, recipients used PCASG funds to
support services for almost 252,000 patients, who had over 1 million
interactions with a health care provider.
Other federal hurricane relief funds helped PCASG fund recipients pay
staff, purchase equipment, and expand mental health services to help
restore primary care. According to data from the Louisiana Department
of Health and Hospitals, 11 recipients received HHS Social Services
Block Grant (SSBG) supplemental funds designated by Louisiana for
primary care, and 2 received SSBG supplemental funds designated by
Louisiana specifically for mental health care. The funds designated for
primary care were used to pay staff and purchase equipment, and the
funds designated for mental health care were used to provide a range of
services including crisis intervention and substance abuse prevention
and treatment. Most of the PCASG fund recipients benefited from the
Professional Workforce Supply Grant incentives. These recipients hired
or retained 69 health care providers who received incentives totaling
over $4 million to work in the greater New Orleans area.
PCASG fund recipients face multiple challenges and have various plans
for sustainability. Recipients face significant challenges in hiring
and retaining staff, as well as in referring patients outside of their
organizations, and these challenges have grown since Hurricane Katrina.
For example, 20 of 23 recipients that responded to the 2008 GAO survey
reported hiring health care providers was a great or moderate
challenge, and over three-quarters of these 20 recipients reported that
this challenge had grown since Hurricane Katrina. PCASG fund recipients
also reported challenges in referring patients outside their
organization for mental health, dental, and specialty care services.
Although all PCASG fund recipients have completed or planned actions to
increase their ability to be sustainable, recipients are concerned
about what will happen when PCASG funds are no longer available.
Officials of the Louisiana Public Health Institute, which administers
the PCASG locally, expect that some recipients might have to close and
others could be forced to scale back capacity by as much as 30 or 40
percent. They have suggested strategies to decrease what they estimate
would be a $30 million gap in annual revenues when PCASG funds are no
longer available. With the availability of PCASG funds scheduled to end
in less than 10 months, preventing disruptions in the delivery of
primary care services could depend on quickly identifying and
implementing workable sustainability strategies.
View [hyperlink, http://www.gao.gov/products/GAO-10-273T] or key
components. For more information, contact Cynthia A. Bascetta at (202)
512-7114 or bascettac@gao.gov.
[End of section]
Mr. Chairman and Members of the Committee:
I am pleased to be here today to discuss primary health care services
in the greater New Orleans area. My testimony is based primarily on our
July 2009 report entitled Hurricane Katrina: Federal Grants Have Helped
Health Care Organizations Provide Primary Care, but Challenges Remain.
[Footnote 1] More than 4 years after Hurricane Katrina made landfall on
August 29, 2005, the greater New Orleans area continues to face
challenges in restoring health care services disrupted by the storm.
Before the hurricane, most health care for the low-income and uninsured
population in the area was provided in emergency rooms and outpatient
clinics at Charity and University hospitals, which were part of the
statewide Louisiana State University (LSU) public hospital system.
About half of the hospitals' patients were uninsured, and about one-
third were covered by Medicaid. Following the hurricane and the
subsequent flooding, the hospitals and clinics closed because of the
significant damage they had sustained. In November 2006, LSU reopened
University Hospital under its new, temporary name, Interim LSU Public
Hospital, which is operating at a lower capacity than Charity's and
University's pre-Katrina capacity; Charity Hospital remains closed.
While health care provider organizations in the area were able to
reopen some health care clinics, gaps in the availability of primary
care services[Footnote 2] in the greater New Orleans area remained.
To help address the continuing health care needs of low-income area
residents, the Department of Health and Human Services (HHS) awarded
the $100 million Primary Care Access and Stabilization Grant (PCASG) to
the Louisiana Department of Health and Hospitals (LDHH) in July 2007.
[Footnote 3] The grant is administered at the federal level by HHS's
Centers for Medicare & Medicaid Services (CMS) and at the local level
by the Louisiana Public Health Institute (LPHI), the local partner of
LDHH. The PCASG is intended to restore and expand access to primary
care services, including mental health care services[Footnote 4] and
dental care services, without regard to a patient's ability to pay, and
to decrease costly reliance on emergency room use for primary care
services for patients who are uninsured, underinsured, or covered by
Medicaid.[Footnote 5] In addition to primary care services, PCASG fund
recipients can use grant funds to provide specialty care, such as
cardiology and podiatry services, and ancillary services, including
supporting services such as translation, transportation, and outreach.
LDHH provided funds to 25 outpatient provider organizations, which we
refer to as PCASG fund recipients. As of March 20, 2008, the recipients
were operating 75 sites that were eligible to use PCASG funds.[Footnote
6] For an organization to be eligible for PCASG funding, it must have
been a public or private nonprofit organization serving patients in the
greater New Orleans area at the time that Louisiana's grant proposal
was submitted. It must also have had the intent to be sustainable, that
is, able to continue providing primary care after PCASG funds are no
longer available.[Footnote 7] The PCASG was given only to the state of
Louisiana. PCASG funds were made available to Louisiana for a 3-year
period, from July 23, 2007, through September 30, 2010. As of June 22,
2009, PCASG fund recipients had received more than $80 million in PCASG
funds.
Since the disruption to the health care system caused by the hurricane,
several HHS agencies have awarded other grants that facilitate access
to primary care. However, like the PCASG funding, much of the funding
is temporary. HHS's Administration for Children and Families provided
Social Services Block Grant (SSBG) supplemental funds to Louisiana,
which subsequently dedicated a portion specifically for health care
services, including mental health care.[Footnote 8] The Secretary of
HHS awarded Professional Workforce Supply Grant funds to reduce
shortages in the professional health care workforce. The funds were
distributed as financial incentives to eligible health care providers;
eligibility requirements included agreeing to serve Medicare, Medicaid,
and uninsured patients.[Footnote 9] Grants from the Health Center
Program of HHS's Health Resources and Services Administration (HRSA)
were also available during this time to certain organizations providing
primary care services. Under Section 330 of the Public Health Service
Act, HRSA provides grants to health centers nationwide to increase
access to primary care, using a competitive process to award grants.
All health center grantees are Federally Qualified Health Centers
(FQHC), which enjoy certain federal benefits such as enhanced Medicare
and Medicaid payment rates. However, not all FQHCs receive Health
Center Program grants, and those that do not are sometimes referred to
as having an FQHC Look-Alike designation. Four health center grantees
served the greater New Orleans area at the time HHS awarded the PCASG
in July 2007.
My statement today is based primarily on our July 2009 report on the
PCASG, in which we examined (1) how PCASG fund recipients used the
PCASG funds to support the provision of primary care services in the
greater New Orleans area, (2) how PCASG fund recipients used and
benefited from other federal hurricane relief funds that support the
restoration of primary care services in the greater New Orleans area,
and (3) challenges the PCASG fund recipients continued to face in
providing primary care services, and recipients' plans for sustaining
services after PCASG funds are no longer available. In addition, we
updated selected information from our 2009 PCASG report and relied on
other related GAO work.
To do the work for our July 2009 report on how federal grants helped
support primary care, we conducted site visits at 8 of the 25 PCASG
fund recipients during April 2008, during which we collected documents
and interviewed PCASG fund recipient, state, and local officials. Based
in part on information we gathered during the site visits, we developed
a Web-based survey that focused on how recipients used PCASG funds, the
challenges they continued to face, and their plans for sustainability.
We administered the survey in October 2008. We received responses from
23 of the 25 recipients, a response rate of 92 percent. We also
reviewed and analyzed data from LDHH on expenditures related to the
supplemental SSBG and on awards made under CMS's Professional Workforce
Supply Grant Program, reviewed the recipients' applications for PCASG
funding and their plans for sustainability, and interviewed officials
at LDHH and PCASG fund recipients about how the recipients used PCASG
and other federal funds. We conducted the work for our July 2009 report
from February 2008 through June 2009. To update the work on the PCASG,
we interviewed state, LPHI, and PCASG fund recipient officials about
sustainability plans and reviewed and analyzed more recent data from
these officials about program funding and services. We conducted this
new work in October and November 2009 and shared the information we
obtained with HHS officials. In addition, we incorporated findings from
another July 2009 report, which examined barriers to mental health
services for children in the greater New Orleans area.[Footnote 10] We
conducted the original and updated work in accordance with all sections
of GAO's Quality Assurance Framework that are relevant to our
objectives. The framework requires that we plan and perform the
engagement to obtain sufficient and appropriate evidence to meet our
stated objectives and to discuss any limitations in our work. We
believe that the information and data obtained, and the analysis
conducted, provide a reasonable basis for any findings and conclusions
in this product. A detailed explanation of our methodology for each of
the 2009 reports is included in the respective reports.
PCASG Fund Recipients Used PCASG Funds to Support Primary Care Services
by Hiring Health Care Providers and Other Staff and Adding Services and
Sites:
PCASG fund recipients that responded to our October 2008 survey
reported that they used PCASG funds to hire or retain health care
providers and other staff, add primary care services, and open new
sites. (See table 1.) Recipients also said that the PCASG funds helped
them improve service delivery and access to care for the patients they
served. As of September 20, 2009, PCASG recipients reported to LPHI
that they had used PCASG funds--in conjunction with other funds, such
as other federal grants and Medicaid reimbursement--to support services
provided to almost 252,000 patients. These patients had over 1 million
encounters with a health care provider, two-thirds of which were for
medical and dental care and one-third of which were for mental health
care.[Footnote 11] A small number of encounters were for specialty
care. The patients served by the PCASG fund recipients were typically
uninsured or enrolled in Medicaid. We reported in July 2009 that for
the first several months during which PCASG funds were available, at
more than half of the PCASG fund recipients, at least half--and at
times over 70 percent--of the patient population was uninsured.
Table 1: Number of Primary Care Access and Stabilization Grant (PCASG)
Fund Recipients That Used PCASG Funds to Hire or Retain Staff, Expand
Services, or Open or Renovate Sites, as of October 28, 2008:
Actions taken with PCASG funds: Hired health care providers;
Number of PCASG fund recipients taking action: 20.
Actions taken with PCASG funds: Hired other staff;
Number of PCASG fund recipients taking action: 18.
Actions taken with PCASG funds: Retained health care providers;
Number of PCASG fund recipients taking action: 17.
Actions taken with PCASG funds: Retained other staff;
Number of PCASG fund recipients taking action: 15.
Actions taken with PCASG funds: Added or expanded primary care
services;
Number of PCASG fund recipients taking action: 19.
Actions taken with PCASG funds: Opened new or relocated sites;
Number of PCASG fund recipients taking action: 15.
Actions taken with PCASG funds: Renovated existing sites;
Number of PCASG fund recipients taking action: 10.
Source: GAO analysis of PCASG fund recipients' responses to GAO's Web-
based survey.
Note: The data in the table are based on the responses of the 23
recipients that responded to GAO's Web-based survey. Recipients may
have hired or retained more than one type of staff and added or
expanded more than one type of service.
[End of table]
Of the 20 recipients that reported in our October 2008 survey that they
used PCASG funds to hire health care providers, half hired both medical
and mental health providers. (See figure 1.) One recipient reported
that by hiring one psychiatrist, it could significantly increase
clients' access to services by cutting down a clinic's waiting list and
by providing clients with a "same-day" psychiatric consultation or
evaluation. Another recipient reported that it hired 23 medical care
providers, some of whom were staffed at its new sites. Some recipients
reported that hiring additional providers enabled them to expand the
hours some of their sites were open.
Figure 1: Number of Primary Care Access and Stabilization Grant (PCASG)
Fund Recipients That Used PCASG Funds to Hire Health Care Providers, as
of October 28, 2008:
[Refer to PDF for image: illustration]
The illustration depicts two overlapping circles containing the
following data:
4 recipients reported hiring only medical health care providers;
6 recipients reported hiring only mental health care providers;
10 recipients reported hiring both medical and mental health care
providers.
Source: GAO analysis of PCASG fund recipients‘ responses to GAO‘s Web-
based survey.
Note: The data in the figure are based on the responses of the 23
recipients that responded to GAO's Web-based survey.
[End of figure]
Of the 23 recipients that responded to our survey, 17 reported they
used PCASG funds to retain health care providers, and 15 of these
reported that they also used grant funds to retain other staff. For
example, one recipient reported that PCASG funds were used to stabilize
positions that were previously supported by disaster relief funds and
donated services.
Nineteen of the 23 PCASG fund recipients that responded to our survey
reported using PCASG funds to add or expand medical, mental health, or
dental care services, and more than half of these added or expanded
more than one type of service. Specifically, 11 added or expanded
medical care, 15 added or expanded mental health care, and 4 added or
expanded dental care services. In addition, PCASG fund recipients also
reported using grant funds to add or expand specialty care or ancillary
services. One recipient reported that it used PCASG funds to create a
television commercial announcing that a clinic was open and that
psychiatric services were available there, including free care for
those who qualified financially.
Almost all of the PCASG fund recipients that responded to our survey
reported they used PCASG funds for their physical space. Ten recipients
that responded to our survey reported using grant funds to renovate
existing sites, such as expanding a waiting room, adding a registration
window, and adding patient restrooms, to accommodate more patients.
Officials from one PCASG fund recipient reported that relocating to a
larger site allowed providers to have additional examination rooms.
PCASG fund recipients that responded to our survey reported that
certain program requirements--such as developing a network of local
specialists and hospitals for patient referrals and establishing a
quality assurance and improvement program that includes clinical
guidelines or evidence-based standards of care--have had a positive
effect on their delivery of primary care services. In addition, they
reported that the PCASG funds helped them improve access to health care
services for residents of the greater New Orleans area. For example,
one PCASG fund recipient reported that the PCASG funds have helped it
to expand services beyond residents in shelter and housing programs to
include community residents who were not homeless but previously lacked
access to health care services. Representatives of other PCASG fund
recipients have reported that their organization improved access to
care by expanding services in medically underserved neighborhoods or to
people who were uninsured or underinsured. Representatives of local
organizations also told us the PCASG provided an opportunity to rebuild
the health care system and shift the provision of primary care from
hospitals to community-based primary care clinics.
Other Federal Hurricane Relief Funds Helped PCASG Fund Recipients to
Pay Staff, Purchase Equipment, and Expand Mental Health Services to
Help Restore Primary Care:
PCASG fund recipients also used other federal hurricane relief funds to
help support the restoration of primary care services. According to
LDHH data, as of August 2008, 11 PCASG fund recipients expended $12.9
million of the SSBG supplemental funds that were awarded to Louisiana
and that the state designated for primary care.[Footnote 12] They used
these funds to pay for staff salaries, purchase medical equipment, and
support operations. For example, one recipient used SSBG supplemental
funds to hire new medical and support staff and, as a result, expanded
its services for mammography, cardiology, and mental health. The two
PCASG fund recipients that received a total of almost $12 million in
SSBG supplemental funds designated for mental health care used those
funds to provide crisis intervention, substance abuse, and other mental
health services, mostly through contracts to other organizations and
providers.[Footnote 13] The majority of funds were expended on the
categories LDHH identified as "substance abuse treatment and prevention
services," "immediate intervention and crisis response services," and
"behavioral health services for children and adolescents."[Footnote 14]
As of August 2008, most of the 25 PCASG fund recipients had retained or
hired a health care provider who had received a Professional Workforce
Supply Grant incentive payment to continue or begin working in the
greater New Orleans area.[Footnote 15] Among the health care providers
working for PCASG fund recipients, 69 received incentives that totaled
$4.5 million. The number of those health care providers who were
employed by individual PCASG fund recipients ranged from 1 or 2 at 7
recipient organizations to 10 at 2 recipient organizations. Three-
quarters of recipients of incentive payments were existing employees
who were retained, while one-quarter were newly hired.
PCASG Fund Recipients Face Multiple Challenges and Have Various Plans
for Sustainability:
PCASG fund recipients face significant challenges in hiring and
retaining staff, as well as in referring patients outside of their
organizations, and these challenges have grown since Hurricane Katrina.
Recipients are taking actions to address the challenge of
sustainability, but are concerned about what will happen when PCASG
funds are no longer available.
PCASG Fund Recipients Face Significant Staffing and Referral
Challenges, and These Challenges Have Grown Since Hurricane Katrina:
Although most of the 23 PCASG fund recipients that responded to our
October 2008 survey hired or retained staff with grant funds, most have
continued to face significant challenges in hiring and retaining staff.
Twenty of the 23 recipients reported the hiring of health care
providers to be either a great or moderate challenge. Among those, over
three-quarters responded that this challenge had grown since Hurricane
Katrina. For example, in discussing challenges, officials from one
recipient organization told us that after Hurricane Katrina they had
greater difficulty hiring licensed nurses than before the hurricane and
that most nurses were being recruited by hospitals, where the pay was
higher. Moreover, officials we interviewed from several recipient
organizations said that the problems with housing, schools, and overall
community infrastructure that developed after Hurricane Katrina made it
difficult to attract health care providers and other staff. In
addition, 16 of the 23 recipients reported that retaining health care
providers was a great or moderate challenge. Among those, about three-
quarters also reported that this challenge had grown since Hurricane
Katrina.
An additional indication of the limited availability of primary care
providers in the area is HRSA's designation of much of the greater New
Orleans area as health professional shortage areas (HPSA) for primary
care, mental health care, and dental care.[Footnote 16] Specifically,
HRSA designated all of Orleans, Plaquemines, and St. Bernard parishes,
and much of Jefferson Parish, as HPSAs for primary care. While some
portions of the greater New Orleans area had this HPSA designation
before Hurricane Katrina, additional portions of the area received that
designation after the hurricane. Similarly, HRSA designated all four
parishes of the greater New Orleans area as HPSAs for mental health in
late 2005 and early 2006; before Hurricane Katrina, none of the four
parishes had this designation for mental health. In addition, HRSA has
designated all of Orleans, St. Bernard, and Plaquemines parishes and
part of Jefferson Parish as HPSAs for dental care; before Katrina, only
parts of Orleans and Jefferson parishes had this designation.
The PCASG fund recipients that primarily provide mental health services
in particular faced challenges both in hiring and in retaining
providers. Six of the seven that responded to our October 2008 survey
reported that both hiring and retaining providers were either a great
or moderate challenge. Officials we interviewed from one recipient told
us that while the Greater New Orleans Service Corps, which was funded
through the Professional Workforce Supply Grant, had been helpful for
recruiting and retaining physicians, it had not helped fill the need
for social workers. Furthermore, officials we interviewed from two
recipients told us that some staff had experienced depression and
trauma themselves and found it difficult to work in mental health
settings. Beyond challenges in hiring and retaining their own providers
and other staff, PCASG fund recipients that responded to our survey
reported significant challenges in referring their patients to other
organizations for mental health, dental, and specialty care services.
We also reported on a lack of mental health providers in our July 2009
report that examined barriers to mental health services for children in
the greater New Orleans area.[Footnote 17] Specifically, 15 of the 18
organizations we interviewed for that work identified a lack of mental
health providers--including challenges recruiting and retaining child
psychiatrists, psychologists, and nurses--as a barrier to providing
mental health services for children. In addition, we reported that
HRSA's Area Resource File (ARF)--a county-based health resources
database that contains data from many sources including the U.S. Census
Bureau and the American Medical Association--indicated that the greater
New Orleans area has experienced more of a decrease in mental health
providers than some other parts of the country. For example, we found
that ARF data documented a 21 percent decrease in the number of
psychiatrists in the greater New Orleans area from 2004 to 2006, during
which time there was a 1 percent decrease in Wayne County, Michigan
(which includes Detroit and which had pre-Katrina poverty and
demographic characteristics similar to those of the greater New Orleans
area) and a 3 percent increase in counties nationwide.
PCASG Fund Recipients Are Taking Actions to Address the Challenge of
Sustainability, but Are Concerned About What Will Happen When PCASG
Funds Are No Longer Available:
In our July 2009 report on the PCASG, we found that an additional
challenge that the PCASG fund recipients face is to be sustainable
after PCASG funds are no longer available in September 2010.[Footnote
18] All 23 recipients that responded to our October 2008 survey
reported that they had taken or planned to take at least one type of
action to increase their ability to be sustainable--that is, to be able
to serve patients regardless of the patients' ability to pay after
PCASG funds are no longer available. For example, all responding
recipients reported that they had taken action--such as screening
patients for eligibility--to facilitate their ability to receive
reimbursement for services they provided to Medicaid or LaCHIP[Footnote
19] beneficiaries.[Footnote 20] Furthermore, 16 recipients that
responded to our October 2008 survey reported that they were billing
private insurance, with an additional 5 recipients reporting they
planned to do so. However, obtaining reimbursement for all patients who
are insured may not be sufficient to ensure a recipient's
sustainability, because at about half of the PCASG fund recipients,
over 50 percent of the patients were uninsured.
Many PCASG fund recipients reported that they intended to use Health
Center Program funding or FQHC Look-Alike designation--which allows for
enhanced Medicare and Medicaid payment rates--as one of their
sustainability strategies. Four recipients were participating in the
Health Center Program at the time they received the initial
disbursement of PCASG funds. One of these recipients had received a
Health Center New Access Point[Footnote 21] grant to open an additional
site after Hurricane Katrina and had also received an Expanded Medical
Capacity[Footnote 22] grant to increase service capacity, which it used
in part to hire additional staff and buy equipment. Another of these
recipients received a New Access Point grant to open an additional site
after receiving PCASG funds. Beyond these four recipients, one
additional recipient received an FQHC Look-Alike designation in July
2008.
HRSA made additional grants from appropriations made available by the
American Recovery and Reinvestment Act of 2009, awarding five PCASG
fund recipients with additional Health Center Program grants totaling
$7.4 million as of October 19, 2009.[Footnote 23] Specifically, three
PCASG fund recipients were awarded New Access Point grants totaling
$3.9 million,[Footnote 24] five received Capital Improvement Program
grants totaling more than $2.4 million,[Footnote 25] and five received
Increased Demand for Services grants totaling nearly $1.1 million.
[Footnote 26]
Of the remaining 18 recipients that responded to our survey, 6 said
they planned to apply for both a Health Center Program grant and an
FQHC Look-Alike designation. In addition, one planned to apply for a
grant only and another planned to apply for an FQHC Look-Alike
designation only. Although many recipients indicated that they intended
to use Health Center Program funding as a sustainability strategy, it
is unlikely that they would all be successful in obtaining a grant. For
example, in fiscal year 2008 only about 16 percent of all applications
for New Access Point grants resulted in grant awards.
About three-quarters of PCASG fund recipients reported that as one of
their sustainability strategies they had applied or planned to apply
for additional federal funding, such as Ryan White HIV/AIDS Program
grants,[Footnote 27] or for state funding. In addition, a few reported
that they had applied or planned to apply for private grants, such as
grants from foundations.
In our fall 2009 interviews, LPHI and PCASG recipient officials told us
that there is uncertainty and concern among the PCASG fund recipients
as the time approaches when PCASG funding will no longer be available.
LPHI officials told us that they expect that some PCASG fund recipients
might have to close, and others could be forced to scale back their
current capacity by as much as 30 or 40 percent. For example, one PCASG
fund recipient official we spoke with in November 2009 told us that the
organization's mobile medical units may not be sustainable without
PCASG funding; services provided by mobile units are not eligible for
Medicaid funding without a referral and collecting cash from patients
could make the units targets for crime. LPHI officials said they expect
that the loss of PCASG funds would most affect PCASG fund recipients
that serve the largest number of uninsured patients.
To help PCASG fund recipients achieve sustainability, the LPHI
developed a sustainability strategy guide in April 2009. This guide
suggests actions that the recipients could take to become sustainable
entities, such as maximizing revenues by improving their ability to
screen patients for eligibility for Medicaid and other third party
payers, enroll eligible patients, electronically bill the insurers, and
collect payment from insurers.
LPHI and a PCASG fund recipient have identified additional potential
approaches for securing revenues to decrease what LPHI estimated would
be a $30 million gap in the PCASG fund recipients' annual revenues when
PCASG funds are no longer available. The LPHI sustainability strategy
guide proposed that expanding Medicaid eligibility through a proposed
Medicaid demonstration project that HHS is reviewing could result in a
decrease in the number of uninsured people; these are the patients for
whom PCASG fund recipients are most dependent on federal subsidies.
[Footnote 28] The LPHI guide also suggested that it could be helpful if
Louisiana received greater flexibility to use Medicaid disproportionate
share dollars for outpatient primary care not provided by hospitals.
[Footnote 29] In addition, a PCASG fund recipient official told us in
November 2009 that a no-cost extension for PCASG funds might help some
PCASG fund recipients if they are able to stretch their PCASG dollars
beyond September 30, 2010.
Although PCASG fund recipients have completed or planned actions to
increase their ability to be sustainable and have received guidance
from LPHI, it is unclear which recipients' sustainability strategies
will be successful and how many patients recipients will be able to
continue to serve. With the availability of PCASG funds scheduled to
end in less than 10 months, preventing disruption in the delivery of
primary care services could depend on quickly identifying and
implementing workable sustainability strategies.
Mr. Chairman, this completes my prepared remarks. I would be happy to
respond to any questions you or other members of the committee may have
at this time.
Contacts and Acknowledgments:
For further information about this statement, please contact Cynthia A.
Bascetta at (202) 512-7114 or bascettac@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this statement. Key contributors to this statement
were Helene F. Toiv, Assistant Director; Carolyn Feis Korman; Deitra
Lee; Coy J. Nesbitt; Roseanne Price; and Jennifer Whitworth.
[End of section]
Footnotes:
[1] See GAO, Hurricane Katrina: Federal Grants Have Helped Health Care
Organizations Provide Primary Care, but Challenges Remain, [hyperlink,
http://www.gao.gov/products/GAO-09-588] (Washington, D.C.: July 13,
2009). In this statement we follow the Centers for Medicare & Medicaid
Services' definition of the greater New Orleans area--Jefferson,
Orleans, Plaquemines, and St. Bernard parishes--which is used by the
program at the center of this statement, the Primary Care Access and
Stabilization Grant.
[2] In this statement, we define primary care as basic medical care
that is generally provided in an outpatient setting such as a clinic or
general practitioner's office, as opposed to in a hospital.
[3] This grant was made under a provision of the Deficit Reduction Act
of 2005 authorizing payments to restore access to health care in
communities affected by Hurricane Katrina. Pub. L. No. 109-171, §
6201(a)(4), 120 Stat. 4, 133 (2006). Notice of Single Source Grant
Award, 72 Fed. Reg. 51,230 (Sept. 6, 2007).
[4] In this statement, we define mental health care services to include
substance abuse prevention and treatment services.
[5] Medicaid is a federal-state health insurance program for certain
low-income individuals.
[6] March 20, 2008, was the end date of the first period for which
recipients of PCASG funds reported data on their activities to LPHI. In
this statement, we describe the data for this period at the recipient
level. As of September 20, 2009, the 25 PCASG fund recipients were
operating 93 sites that were eligible to use those funds.
[7] For the PCASG, CMS defines sustainability as the ability to
continue to provide primary care to all patients (regardless of their
ability to pay) through some funding mechanism other than the PCASG
funds, such as enrolling as a provider in Medicaid or another public or
private insurer.
[8] To help respond to the short-term crisis counseling needs, the
greater New Orleans area also received federal Crisis Counseling
Assistance and Training Program funds. See GAO, Catastrophic Disasters:
Federal Efforts Help States Prepare for and Respond to Psychological
Consequences, but FEMA‘s Crisis Counseling Program Needs Improvements,
[hyperlink, http://www.gao.gov/products/GAO-08-22] (Washington, D.C.:
Feb. 29, 2008).
[9] Financial incentive payments could be given to health care
providers who remained in their qualifying job or to newly hired health
care providers; individuals may receive only one financial incentive
payment.
[10] GAO, Hurricane Katrina: Barriers to Mental Health Services for
Children Persist in Greater New Orleans, Although Federal Grants Are
Helping to Address Them, [hyperlink,
http://www.gao.gov/products/GAO-09-563] (Washington, D.C.: July 13,
2009).
[11] An encounter is an interaction between a patient and a provider
for the purposes of meeting a health care need. It can occur by
telephone or in person.
[12] The SSBG supplemental funds were distributed before organizations
received PCASG funds. Dollar amounts reflect funds expended by PCASG
fund recipients at sites where they later used PCASG funds.
[13] None of the contracts were awarded to other PCASG fund recipients.
[14] Behavioral health is a term often used to refer to mental health
and substance abuse services.
[15] In discussing the incentive payments made from Professional
Workforce Supply Grant funds, the information we provide about the 25
PCASG fund recipients is based on the more than 80 sites that were also
eligible to use PCASG funds as of August 2008. Additional health care
providers who have received incentives may be employed by PCASG fund
recipients, but not at sites eligible to use PCASG funds.
[16] HPSAs are used to identify geographic areas, population groups, or
facilities facing a shortage of primary care, dental, or mental health
providers.
[17] [hyperlink, http://www.gao.gov/products/GAO-09-563].
[18] [hyperlink, http://www.gao.gov/products/GAO-09-588].
[19] LaCHIP is the name of Louisiana's Children's Health Insurance
Program. The Children's Health Insurance Program is a federal-state
health insurance program that offers insurance to certain children
under age 19 whose family income is too high for Medicaid eligibility
and who are not enrolled under other health insurance.
[20] From September 2007 to September 2009, there was a 20 percent
increase in the number of PCASG recipients' clinics that billed
Medicaid, according to data from LPHI.
[21] New Access Point grants are for new grantees or for existing
grantees to establish additional sites.
[22] Expanded Medical Capacity grants support increased service
capacity, such as by expanding operating hours.
[23] The American Recovery and Reinvestment Act of 2009 provided HRSA
with $2 billion for the Health Center Program (Pub. L. No. 111-5, div.
A, title VIII, 123 Stat. 115, 175).
[24] One of the three PCASG fund recipients that were awarded New
Access Point grants was the one that received Look-Alike designation in
2008; the other two were existing grantees.
[25] Capital Improvement Program grants are limited-competition awards
designed to address capital improvement needs in health centers, such
as construction, repairs, renovation, and equipment purchase, including
health information technology.
[26] Increased Demand for Services grants are formula allocation awards
designed to help health centers increase the number of total patients
and uninsured patients served, such as by extending hours of operation,
expanding existing services, adding staff, or retaining staff.
[27] Through the Ryan White Comprehensive AIDS Resources Emergency Act
of 1990 and subsequent legislation, HRSA provides federal funds to
metropolitan areas, states, and others to assist with the cost of core
medical and support services for individuals and families infected and
affected by HIV/AIDS. See 42 U.S.C. §§ 300ff through 300ff-121.
[28] States operate and administer their Medicaid programs
independently within federal requirements established in statute and
regulations, and the federal government shares in the cost of each
state's program by paying an established share of states' reported
expenditures. Under section 1115 of the Social Security Act, however,
the Secretary of HHS may waive certain federal requirements for
demonstrations the Secretary deems likely to promote Medicaid
objectives, allowing states to apply to test and evaluate new
approaches for delivering Medicaid services.
[29] Medicaid disproportionate share hospital payments provide
financial assistance to hospitals that serve a large number of low-
income patients, such as people with Medicaid and the uninsured.
Medicaid disproportionate share hospital payments are the largest
source of federal funding for uncompensated hospital care.
[End of section]
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "E-mail Updates."
Order by Phone:
The price of each GAO publication reflects GAO‘s actual cost of
production and distribution and depends on the number of pages in the
publication and whether the publication is printed in color or black and
white. Pricing and ordering information is posted on GAO‘s Web site,
[hyperlink, http://www.gao.gov/ordering.htm].
Place orders by calling (202) 512-6000, toll free (866) 801-7077, or
TDD (202) 512-2537.
Orders may be paid for using American Express, Discover Card,
MasterCard, Visa, check, or money order. Call for additional
information.
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Ralph Dawn, Managing Director, dawnr@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548:
