Hurricane Katrina
Status of Hospital Inpatient and Emergency Departments in the Greater New Orleans Area Gao ID: GAO-06-1003 September 29, 2006In the aftermath of Hurricane Katrina, questions remain concerning the availability of hospital inpatient care and emergency department services in the greater New Orleans area--which consists of Jefferson, Orleans, Plaquemines, and St. Bernard parishes. Because of broad-based congressional interest, GAO, under the Comptroller General's statutory authority to conduct evaluations, assessed efforts to restore the area's hospitals by the Department of Homeland Security's (DHS) Federal Emergency Management Agency (FEMA); the Department of Health and Human Services (HHS); and the Louisiana State University (LSU) public hospital system, which operated Charity and University hospitals in New Orleans. GAO examined (1) the availability of hospital inpatient care and the demand for emergency department services, (2) steps taken to reopen Charity and University hospitals, and (3) the activities that HHS has undertaken to help hospitals recover. To fulfill these objectives, GAO reviewed documents and interviewed federal officials and hospital, state, and local officials in the greater New Orleans area. GAO also obtained information on the number of inpatient beds for April 2006, which was the most recent data available when GAO did its work. GAO's work did not include other issues related to hospitals such as outpatient services or financial condition.
While New Orleans continues to face a range of health care challenges, hospital officials in the greater New Orleans area reported in April 2006 that a sufficient number of staffed inpatient beds existed for all services except for psychiatric care--some psychiatric patients had to be transferred out of the area because of a lack of beds. Overall, GAO determined that the area had about 3.2 staffed beds per 1,000 population, compared with a national average of 2.8 staffed beds per 1,000 population. Hospital officials told GAO they planned to open an additional 674 staffed beds by the end of 2006, although they reported that recruiting, hiring, and retaining nurses and support staff was a great challenge. With these additional beds, the population would have to increase from 588,000 in April 2006 to 913,000 by December 2006 before staffed beds would drop to the national average. Hospitals also reported a high demand for emergency services, consistent with a June 2006 Institute of Medicine report, which found that emergency department crowding is a nationwide problem. Steps have been taken to reopen University Hospital, but as of July 2006, LSU had no plans to reopen Charity Hospital. LSU plans to open portions of University Hospital in fall 2006 and would like to replace both hospitals with a new one. LSU and FEMA have prepared cost estimates to repair these hospitals. For Charity Hospital, FEMA's estimate of $27 million is much lower than LSU's estimate of $258 million, which covers, for example, repairing hurricane damage and correcting many prestorm deficiencies. In contrast, FEMA's estimate covers repairs for hurricane damage only--the only repair costs eligible for federal reimbursement. HHS provided financial assistance and waived certain program requirements to help hospitals recover in the area. For example, HHS included $221 million in hurricane relief funds designated for Louisiana through Social Services Block Grants, which may be used in part to reconstruct health care facilities. HHS also waived certain Medicare billing and other requirements and accelerated Medicare payments to providers, including hospitals, in the hurricane-affected states. Rebuilding the health care infrastructure of the greater New Orleans area will depend on many factors, including the health care needs of the population that returns to the city and the state's vision for its future health care system. In light of the current sufficiency of hospital beds for most inpatient services, GAO believes a major challenge facing the greater New Orleans area is attracting and retaining enough nurses and support staff. HHS and the Department of Veterans Affairs (VA) agreed with the draft report. DHS said it had no formal comments on the draft. HHS, VA, DHS, and Louisiana's Department of Health and Hospitals provided technical comments, which GAO incorporated where appropriate. LSU did not provide comments.
GAO-06-1003, Hurricane Katrina: Status of Hospital Inpatient and Emergency Departments in the Greater New Orleans Area
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
September 2006:
Hurricane Katrina:
Status of Hospital Inpatient and Emergency Departments in the Greater
New Orleans Area:
Status of Hospitals in New Orleans:
GAO-06-1003:
GAO Highlights:
Highlights of GAO-06-1003, a report to congressional committees
Why GAO Did This Study:
In the aftermath of Hurricane Katrina, questions remain concerning the
availability of hospital inpatient care and emergency department
services in the greater New Orleans area”which consists of Jefferson,
Orleans, Plaquemines, and St. Bernard parishes. Because of broad-based
congressional interest, GAO, under the Comptroller General‘s statutory
authority to conduct evaluations, assessed efforts to restore the
area‘s hospitals by the Department of Homeland Security‘s (DHS) Federal
Emergency Management Agency (FEMA); the Department of Health and Human
Services (HHS); and the Louisiana State University (LSU) public
hospital system, which operated Charity and University hospitals in New
Orleans. GAO examined (1) the availability of hospital inpatient care
and the demand for emergency department services, (2) steps taken to
reopen Charity and University hospitals, and (3) the activities that
HHS has undertaken to help hospitals recover. To fulfill these
objectives, GAO reviewed documents and interviewed federal officials
and hospital, state, and local officials in the greater New Orleans
area. GAO also obtained information on the number of inpatient beds for
April 2006, which was the most recent data available when GAO did its
work. GAO‘s work did not include other issues related to hospitals such
as outpatient services or financial condition.
What GAO Found:
While New Orleans continues to face a range of health care challenges,
hospital officials in the greater New Orleans area reported in April
2006 that a sufficient number of staffed inpatient beds existed for all
services except for psychiatric care”some psychiatric patients had to
be transferred out of the area because of a lack of beds. Overall, GAO
determined that the area had about 3.2 staffed beds per 1,000
population, compared with a national average of 2.8 staffed beds per
1,000 population. Hospital officials told GAO they planned to open an
additional 674 staffed beds by the end of 2006, although they reported
that recruiting, hiring, and retaining nurses and support staff was a
great challenge. With these additional beds, the population would have
to increase from 588,000 in April 2006 to 913,000 by December 2006
before staffed beds would drop to the national average. Hospitals also
reported a high demand for emergency services, consistent with a June
2006 Institute of Medicine report, which found that emergency
department crowding is a nationwide problem.
Steps have been taken to reopen University Hospital, but as of July
2006, LSU had no plans to reopen Charity Hospital. LSU plans to open
portions of University Hospital in fall 2006 and would like to replace
both hospitals with a new one. LSU and FEMA have prepared cost
estimates to repair these hospitals. For Charity Hospital, FEMA‘s
estimate of $27 million is much lower than LSU‘s estimate of $258
million, which covers, for example, repairing hurricane damage and
correcting many prestorm deficiencies. In contrast, FEMA‘s estimate
covers repairs for hurricane damage only”the only repair costs eligible
for federal reimbursement.
HHS provided financial assistance and waived certain program
requirements to help hospitals recover in the area. For example, HHS
included $221 million in hurricane relief funds designated for
Louisiana through Social Services Block Grants, which may be used in
part to reconstruct health care facilities. HHS also waived certain
Medicare billing and other requirements and accelerated Medicare
payments to providers, including hospitals, in the hurricane-affected
states.
Rebuilding the health care infrastructure of the greater New Orleans
area will depend on many factors, including the health care needs of
the population that returns to the city and the state‘s vision for its
future health care system. In light of the current sufficiency of
hospital beds for most inpatient services, GAO believes a major
challenge facing the greater New Orleans area is attracting and
retaining enough nurses and support staff.
HHS and the Department of Veterans Affairs (VA) agreed with the draft
report. DHS said it had no formal comments on the draft. HHS, VA, DHS,
and Louisiana‘s Department of Health and Hospitals provided technical
comments, which GAO incorporated where appropriate. LSU did not provide
comments.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-1003].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Cynthia
Bascetta at (202) 512-7101 or bascettac@gao.gov or Terrell G. Dorn at
(202) 512-6923 or dornt@gao.gov.
[End of Section]
Contents:
Letter:
Results in Brief:
Background:
Sufficient Staffed Beds Existed for All Types of Inpatient Care Except
Psychiatric Care; High Demand Existed for Emergency Department
Services:
Steps Have Been Taken to Reopen University Hospital, but LSU Has No
Plans to Reopen Charity Hospital:
HHS Has Provided Financial and Technical Assistance and Program Waivers
to Help Address Restoration:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Health and Human Services:
Appendix III: GAO Contacts and Staff Acknowledgments:
Tables:
Table 1: Status of Acute Care Facilities in the Greater New Orleans
Area, April 25, 2006:
Table 2: Number of Available, Staffed, and Occupied Beds by Type of
Care at Hospitals in the Greater New Orleans Area on April 25, 2006:
Table 3: LSU's and FEMA's Cost Estimates for Charity and University
Hospitals:
Figure:
Figure 1: Open and Closed Hospitals in the New Orleans Area as of June
2006:
Abbreviations:
ADA: Americans with Disabilities Act:
ADAMS: ADAMS Management Services Corporation:
CMS: Centers for Medicare & Medicaid Services:
COSG: Collaborative Opportunities Study Group:
DHS: Department of Homeland Security:
FEMA: Federal Emergency Management Agency:
HHS: Department of Health and Human Services:
LSU: Louisiana State University:
MCLNO: Medical Center of Louisiana at New Orleans:
OFPC: Office of Facility Planning and Control:
SSBG: Social Services Block Grant:
VA: Department of Veterans Affairs:
United States Government Accountability Office:
Washington, DC 20548:
September 29, 2006:
Congressional Committees:
Hurricane Katrina, which made landfall near the Louisiana-Mississippi
border on the morning of August 29, 2005, and the subsequent flooding
caused by the failure of the New Orleans levee system resulted in one
of the largest natural disasters ever to hit the United States. Among
the challenges facing the greater New Orleans area[Footnote 1] in the
aftermath of Hurricane Katrina is addressing the significant damage to
hospital facilities, the loss of hospital staff who relocated to other
areas, and the associated disruption of hospital inpatient care and
emergency department services. For example, Charity and University
hospitals, which are part of the statewide Louisiana State University
(LSU) public hospital system, suffered extensive damage as a result of
the hurricane and remained closed as of June 30, 2006.[Footnote 2]
Private hospitals serving the area were also damaged and, like their
public counterparts, have been short of nursing and support staff in
the months following the hurricane.
In responding to a natural disaster such as Hurricane Katrina, the
federal government coordinates operations with state and local
governments and the private sector according to the framework provided
in the National Response Plan.[Footnote 3] Under this plan, the
Department of Homeland Security's (DHS) Federal Emergency Management
Agency (FEMA) has primary responsibility for emergency response and
recovery planning and coordination, and the Department of Health and
Human Services (HHS) has overall responsibility for coordinating public
health and medical response to incidents. HHS is also designated as a
support agency for long-term community recovery and mitigation.
In March 2006, we reported on the status of the health care system in
New Orleans as of that month.[Footnote 4] As we reported, the
availability of health care services--which includes those provided
within and outside of a hospital facility--is one of the factors that
can affect whether and how quickly residents return to an area after a
disaster.[Footnote 5] This report is a follow-up to our March 2006
report and focuses on hospital inpatient care; emergency department
services; and efforts to restore hospital infrastructure, that is,
facilities and staff. Specifically, this report discusses (1) the
availability of hospital inpatient care and the demand for emergency
department services in the greater New Orleans area, (2) steps taken by
FEMA and LSU to reopen Charity and University hospitals, and (3) the
activities that HHS has undertaken to help hospitals recover in the
greater New Orleans area. Because of broad congressional interest, we
performed this work under the Comptroller General's statutory authority
to conduct evaluations on his own initiative.[Footnote 6]
To examine the availability of hospital inpatient care and the demand
for emergency department services, we contacted nine operating public
and private acute care hospitals[Footnote 7] in the greater New Orleans
area to obtain information on the number of available, staffed, and
occupied beds[Footnote 8] for one randomly selected day in April 2006,
and later we asked the hospital officials to provide the same
information for the entire month of April, which was the most recent
data available when we did our work.[Footnote 9] Five hospitals
responded to our request for data for the month of April. We also
obtained hospital estimates of the occupancy rates for the 12-month
period prior to, and the 9-month period after, Hurricane Katrina for 8
of the 9 open hospitals. To determine the April 2006 population of the
four parishes in the greater New Orleans area, we used estimates from
the Louisiana Department of Health and Hospitals Bureau of Primary Care
and Rural Health, which used two methodologies to estimate the
population in each of the parishes. It used school enrollment data for
Jefferson, St. Bernard, and Plaquemines parishes; and for Orleans
Parish it used a survey of persons occupying residential structures.
The survey had been conducted by the New Orleans Health Department in
consultation with the Centers for Disease Control and Prevention. To
examine the demand for emergency department services, we obtained
information on emergency room wait times for 6 hospitals and the number
of times that 8 hospitals diverted patients to other facilities for the
30-day period from March 28, 2006, through April 26, 2006. We limited
our work to examining the status of hospital inpatient and emergency
departments in the greater New Orleans area and did not examine other
aspects of hospital services, such as outpatient services or the
financial condition of the hospitals. We also did not address other
issues related to the health care system, such as the status of primary
care, medical research, or graduate medical education.
To determine the steps that have been taken to reopen Charity and
University hospitals--two public facilities eligible for federal
disaster assistance--we reviewed LSU's and FEMA's damage assessments
and cost estimates for the hospitals and LSU correspondence to FEMA
regarding potential federal funding. We also reviewed FEMA regulations
and guidance pertaining to disaster assistance. We toured Charity and
University hospitals to examine the damage to these facilities. We also
toured two temporary facilities that provided hospital outpatient care
and emergency department services. These two facilities, established by
LSU, were the Elmwood Medical Center and the Medical Center of
Louisiana at New Orleans (MCLNO) Emergency Services Unit.
To determine the activities undertaken by HHS to help hospitals
recover, we reviewed documents outlining HHS programs and activities
related to helping restore hospital inpatient care and emergency
department services after a disaster. We also reviewed written
summaries created by HHS officials to document department activities to
help restore hospital inpatient care and emergency department services
after Hurricane Katrina.
In addressing all three objectives, we interviewed officials from HHS,
FEMA, LSU (including LSU's Health Care Services Division, which manages
the public hospitals in the greater New Orleans area), and seven of the
nine hospitals that we contacted in the greater New Orleans area. We
also interviewed officials from the Department of Veterans Affairs (VA)
because VA is considering building a joint hospital complex with LSU in
New Orleans, the Louisiana Recovery Authority because it is the
planning and coordinating body that was created in the aftermath of
Hurricane Katrina by the Governor of Louisiana to plan for recovery and
rebuilding efforts, and Louisiana's Office of Facility Planning and
Control (OFPC) because it is administering the design and construction
of all Louisiana state-owned facilities damaged by Hurricane Katrina.
We did not independently verify information we received from hospitals
in the greater New Orleans area. We conducted our work from April 2006
through September 2006 in accordance with generally accepted government
auditing standards. See appendix I for more information about our scope
and methodology.
Results in Brief:
While New Orleans continues to face a range of health care challenges,
hospital officials in the greater New Orleans area reported in April
2006 that a sufficient number of staffed inpatient beds existed for all
services except for psychiatric care--some psychiatric patients had to
be transferred out of the area because of a lack of beds. Overall, as
of April 2006, the greater New Orleans area had about 3.2 staffed beds
per 1,000 population, compared with the national average of 2.8 staffed
beds per 1,000 population reported by the American Hospital
Association. Hospital officials told us that they planned to open an
additional 674 staffed beds by the end of 2006--390 of which would be
at University Hospital--although they also reported that recruiting,
hiring, and retaining nurses and support staff was a great challenge.
With the addition of these beds, the population would have to increase
from 588,000 in April 2006 to 913,000 by December 2006 before staffed
beds would drop to the national average. For all types of care, eight
of the nine hospitals we contacted provided us with an estimated
overall occupancy rate for the 9-month period following the hurricane
(through April 2006) and for the 12-month period before the hurricane.
The hospitals' occupancy rates for the 9-month period after the
hurricane ranged from 45 percent to 100 percent, or an average of 77
percent, compared with a range from 33 percent to 85 percent, or an
average of 70 percent, for the 12-month period before the hurricane.
The American Hospital Association reported that the average monthly
hospital occupancy rate nationwide was 67 percent in 2004. Eight of the
nine hospitals that remained open after Hurricane Katrina also reported
a high demand for services in their emergency departments, similar to
the nationwide trend reported by the Institute of Medicine in June 2006
that emergency department crowding is a nationwide problem.
Steps have been taken to reopen University Hospital, but as of July
2006, LSU had no plans to reopen Charity Hospital. FEMA and LSU have
prepared damage assessments and cost estimates for these hospitals,
some repairs have begun at University Hospital, and temporary
facilities have been established to provide some services previously
offered at both hospitals. FEMA's cost estimates are considerably lower
than LSU's estimates. For example, LSU estimates the cost of repairing
Charity Hospital at about $258 million, while FEMA estimates the cost
at about $27 million. The difference between these two estimates is
primarily due to two factors. First, LSU's estimate covers whole
building repair, meaning that it includes repairing damage from
Hurricane Katrina as well as correcting many deficiencies that had been
identified before the hurricane. In contrast, FEMA's estimate covers
repair costs for hurricane damage from flooding and wind only, since
these are the only repair costs eligible for federal reimbursement.
Second, in anticipation of a shortage of materials and labor over the
next 3 to 6 years as a result of the hurricane, LSU's estimate includes
a 66 percent cost escalation over a commonly used index of labor and
material for New Orleans, while FEMA's estimate does not include such a
cost escalation. According to FEMA, a cost escalation for materials and
labor was not warranted based on FEMA's recent contracting experience
in the area. Repairs are currently under way to reopen portions of
University Hospital (e.g., inpatient beds and a pharmacy) beginning in
late September or early October. As of July 2006, LSU had no plans to
reopen Charity Hospital. Rather, LSU is pursuing the possibility of a
new facility to replace both Charity and University hospitals in the
future. If LSU decides to replace these hospitals, a portion of the
funds FEMA authorized for repair may be used to build this new
hospital. The amount of federal funding available for a new hospital
will depend, in part, on FEMA's initial estimated cost to repair
Charity and University hospitals. In the meantime, LSU has established
temporary facilities to provide some of the hospital functions
previously provided by Charity and University hospitals in the short
term, including an emergency services unit and a trauma center.
HHS has been able to provide financial and technical assistance and has
waived certain program requirements in order to help hospitals recover
in the greater New Orleans area. HHS financial assistance included $221
million in hurricane relief funds designated for Louisiana through
Social Services Block Grants (SSBG); some of these funds may be used to
reconstruct health care facilities. As of June 13, 2006, HHS was
considering four applications from the greater New Orleans area for a
Medicare extraordinary circumstances exception, which allows hospitals
serving Medicare patients to apply for long-term reimbursement for
capital expenditures of greater than $5 million to repair hurricane-
damaged facilities. Technical assistance to Louisiana is both ongoing
and planned. Ongoing technical assistance has included providing
consultation at Orleans Parish health planning committee meetings that
addressed shortages of staff, hospital beds, and funding, and
collaborating with survey agencies and hospitals to coordinate the
application of accreditation standards for temporary hospital
facilities or hurricane-damaged facilities. Planned technical
assistance is part of a broader effort to help redesign Louisiana's
health care delivery system, including the restoration of inpatient
care and emergency department services in the greater New Orleans area.
HHS officials said that this could include assisting Louisiana in
development of future requests for Medicare demonstrations and Medicaid
waivers designed to make Louisiana's health care system more effective
and efficient. HHS has also waived certain Medicare billing and other
requirements and accelerated Medicare payments to providers, including
hospitals, in the hurricane-affected states such as Louisiana.
Based on information provided by hospital officials, we believe a major
challenge facing the greater New Orleans area is to attract sufficient
nurses and support staff to operate the beds that are currently
available. Since the number of staffed and available inpatient beds in
the greater New Orleans area is above the national average, local and
state officials are afforded time to deliberate the appropriate
location and numbers of hospital facilities. Although LSU officials
would prefer to construct a new hospital facility to replace Charity
and University hospitals, decisions on the future of these hospitals
and the overall provision of health care in New Orleans ultimately will
be made at the highest levels of the state government. A number of
federal, state, and local stakeholders will also have input into these
final decisions. The decisions made will depend on a variety of
factors. In addition to the major challenge of attracting and retaining
hospital staff, other challenges will include the availability of
funding, the health care needs of the population that returns to the
city, and the state's vision for the future of its health care system.
Finally, as restoration of hospital inpatient care, emergency services,
and hospital infrastructure proceeds, HHS's efforts to conduct
demonstrations and to waive certain program requirements will continue
to be an important factor in addressing health care needs in the
greater New Orleans area.
In commenting on a draft of this report, HHS and VA agreed with the
draft report. DHS said it had no formal comments on the draft report.
HHS, VA, DHS, and Louisiana's Department of Health and Hospitals
provided technical comments, which we incorporated where appropriate.
LSU did not provide comments.
Background:
Before Hurricane Katrina, 16 acute care hospitals operated in the
greater New Orleans area. These hospitals included public as well as
private for-profit and not-for-profit facilities. Because of the
hurricane and resulting flooding, 7 hospitals remained closed as of
June 2006. (See table 1.)
Table 1: Status of Acute Care Facilities in the Greater New Orleans
Area, April 25, 2006:
Facilities in New Orleans (Orleans Parish)[A]: Charity Hospital;
Available beds: Closed;
Staffed beds: Closed;
Occupied beds: Closed;
Type of facility: Public.
Facilities in New Orleans (Orleans Parish)[A]: Children's Hospital;
Available beds: 201;
Staffed beds: 143;
Occupied beds: 101;
Type of facility: Not-for-profit.
Facilities in New Orleans (Orleans Parish)[A]: Lindy Boggs Medical
Center;
Available beds: Closed;
Staffed beds: Closed;
Occupied beds: Closed;
Type of facility: For-profit.
Facilities in New Orleans (Orleans Parish)[A]: Memorial Medical Center;
Available beds: Closed;
Staffed beds: Closed;
Occupied beds: Closed;
Type of facility: For-profit.
Facilities in New Orleans (Orleans Parish)[A]: Methodist Hospital;
Available beds: Closed;
Staffed beds: Closed;
Occupied beds: Closed;
Type of facility: Not-for-profit.
Facilities in New Orleans (Orleans Parish)[A]: New Orleans VA Medical
Center;
Available beds: Closed;
Staffed beds: Closed;
Occupied beds: Closed
Type of facility: Federal.
Facilities in New Orleans (Orleans Parish)[A]: Touro Infirmary;
Available beds: 297;
Staffed beds: 255;
Occupied beds: 240;
Type of facility: Not-for-profit.
Facilities in New Orleans (Orleans Parish)[A]: Tulane University
Hospital and Clinic;
Available beds: 73;
Staffed beds: 73;
Occupied beds: 64;
Type of facility: Not-for-profit.
Facilities in New Orleans (Orleans Parish)[A]: University Hospital;
Available beds: Closed;
Staffed beds: Closed;
Occupied beds: Closed;
Type of facility: Public.
Facilities in New Orleans (Orleans Parish)[A]: Total;
Available beds: 571;
Staffed beds: 471;
Occupied beds: 405;
Type of facility: [Empty].
Facilities outside of New Orleans (Jefferson and St. Bernard
parishes)[B]: Chalmette Medical Center;
Available beds: Closed;
Staffed beds: Closed;
Occupied beds: Closed;
Type of facility: For-profit.
Facilities outside of New Orleans (Jefferson and St. Bernard
parishes)[B]: East Jefferson General Hospital;
Available beds: 444;
Staffed beds: 430;
Occupied beds: 430;
Type of facility: Public community[C].
Facilities outside of New Orleans (Jefferson and St. Bernard
parishes)[B]: Kenner Regional Medical Center;
Available beds: 205;
Staffed beds: 74;
Occupied beds: 64;
Type of facility: For-profit.
Facilities outside of New Orleans (Jefferson and St. Bernard
parishes)[B]: Meadowcrest Hospital;
Available beds: 172;
Staffed beds: 116;
Occupied beds: 102;
Type of facility: For-profit.
Facilities outside of New Orleans (Jefferson and St. Bernard
parishes)[B]: Ochsner Medical Center;
Available beds: 498;
Staffed beds: 432;
Occupied beds: 394;
Type of facility: Not-for-profit.
Facilities outside of New Orleans (Jefferson and St. Bernard
parishes)[B]: Tulane-Lakeside Hospital;
Available beds: 82;
Staffed beds: 62;
Occupied beds: 28;
Type of facility: For-profit.
Facilities outside of New Orleans (Jefferson and St. Bernard
parishes)[B]: West Jefferson Medical Center;
Available beds: 356;
Staffed beds: 293;
Occupied beds: 265;
Type of facility: Public community[C].
Facilities outside of New Orleans (Jefferson and St. Bernard
parishes)[B]: Total;
Available beds: 1,757;
Staffed beds: 1,407;
Occupied beds: 1,283;
Type of facility: [Empty].
Total for the greater New Orleans area;
Available beds: 2,328;
Staffed beds: 1,878;
Occupied beds: 1,688;
Type of facility: [Empty].
Source: GAO analysis of documentation and interviews with hospital
officials.
Notes: The greater New Orleans area consists of Jefferson, Orleans,
Plaquemines, and St. Bernard parishes. We did not include Elmwood
Medical Center, a trauma center in Jefferson Parish, because it is a
temporary facility that opened on April 24, 2006, after our survey
began.
[A] New Orleans and Orleans Parish have the same geographical
boundaries.
[B] Plaquemines Parish did not have an acute care hospital before
Hurricane Katrina.
[C] East Jefferson General Hospital and West Jefferson Medical Center
are publicly owned, not-for-profit community service district hospitals
organized by the parish and governed by boards of directors. These
hospitals are not part of the statewide system of 10 public hospitals.
[End of table]
Charity and University hospitals are part of the statewide system of 10
public hospitals. Charity Hospital, which served as a Level I trauma
center,[Footnote 10] was built in 1937. University Hospital was built
in 1972. These hospitals served as the primary health care safety net
for many local residents. About half of the patients served by these
hospitals were uninsured, and about one-third were covered by Medicaid,
the federal-state program for financing health care for certain low-
income individuals. Charity and University hospitals served as a major
state resource through training programs for professionals in medicine,
nursing, dentistry, and public health.
Charity and University hospitals are eligible for federal aid under the
Public Assistance program managed by FEMA to help repair the damage
caused by Hurricane Katrina. This program, authorized by the Stafford
Act, provides grants to pay up to 90 percent of the costs of restoring
a facility to predisaster condition.[Footnote 11] A facility is
considered repairable when the cost of repairing disaster damages does
not exceed 50 percent of the cost of replacing the facility and it is
feasible to repair the facility so that it can perform the function for
which it was being used as well as it did immediately prior to the
disaster.[Footnote 12] Although initial grant obligations are based on
FEMA's estimate of the costs of repairs to restore the facility to its
predisaster condition, reimbursements are based on actual, documented
repair costs, which could be higher than the original estimate.
Alternatively, if FEMA's estimated repair costs exceed 50 percent of
its estimated replacement costs, FEMA is authorized to grant up to 90
percent of its estimated replacement costs to replace a facility. There
is a possibility for additional federal reimbursements under the Public
Assistance program for required code upgrades that are triggered by the
repairs. Code upgrades, although eligible for reimbursements, are not
included in determining whether repair costs exceed 50 percent of
replacement costs. In the event that FEMA's estimated repair costs do
not exceed 50 percent of its estimated replacement costs and a decision
is made to replace rather than repair, funds authorized for repair may
be used to build a new hospital, but reimbursements will be limited to
90 percent of FEMA's estimated cost to repair and restore the original
facility to its predisaster condition. In addition, projects for hazard
mitigation to prevent damage in future flooding events are eligible for
Public Assistance funding.
HHS is the federal government's principal agency for protecting the
health of all Americans and providing essential human services. HHS's
Centers for Medicare & Medicaid Services (CMS) administers Medicare,
which finances health care for elderly and certain disabled
individuals, and Medicaid. In its support role for long-term community
recovery and mitigation under the National Response Plan, HHS
coordinates federal government health care support to state, regional,
local, and tribal governments; nongovernmental organizations; and the
private sector to enable community recovery, such as recovery from the
long-term consequences of Hurricane Katrina and the subsequent
flooding.
Sufficient Staffed Beds Existed for All Types of Inpatient Care Except
Psychiatric Care; High Demand Existed for Emergency Department
Services:
In the greater New Orleans area, a sufficient number of staffed
hospital inpatient beds existed for all types of care except
psychiatric care; there was also a high demand for emergency department
services. According to information we obtained from hospital officials,
we determined that as of April 2006 the greater New Orleans area had
more staffed beds per 1,000 population than the national average, and
over two-thirds of these beds were within 5 miles of Charity and
University hospitals.[Footnote 13] While hospitals were able to
maintain a sufficient number of staffed beds, hospital officials also
reported that recruiting, hiring, and retaining nurses and support
staff, such as nursing aids, housekeepers, and food service workers, to
staff the available beds constituted a great challenge. Eight of the
nine hospitals that remained open after Hurricane Katrina reported a
high demand for services in their emergency departments, not unlike
emergency departments in other parts of the country, which are also
experiencing high demand.
Staffed Beds per 1,000 Population Exceeded National Average:
According to information we obtained from hospital officials, we
determined that as of April 2006, the greater New Orleans area had more
staffed beds per 1,000 population than the national average. Before
Hurricane Katrina, the population of the greater New Orleans area was
about 1,002,000, with about 455,000 living within the city boundaries
of New Orleans (Orleans Parish). The number of staffed hospital
inpatient beds on hand to serve the people of the greater New Orleans
area was 3,958, or about 4.0 staffed beds per 1,000 population, as
compared with the national average of 2.8 staffed beds per 1,000
population reported in 2006.[Footnote 14] The population of the greater
New Orleans area remains in flux and is difficult to estimate, in part
due to former residents living outside the city and returning during
the day and workers involved in reconstruction activities.
PricewaterhouseCoopers[Footnote 15] estimated the February 2006
population of the four parishes (Orleans, Jefferson, Plaquemines, and
St. Bernard) to be 578,000, and the Louisiana Department of Health and
Hospitals[Footnote 16] reported estimates of about 569,000 for January
2006 and 588,000 for April 2006. In April 2006, the hospitals in the
greater New Orleans area reported to us that they were able to staff
1,878 of the 2,328 available beds. Based on their reports and the April
2006 population estimate, we calculated the four parishes had 3.2
staffed beds per 1,000 population and 4.0 available beds per 1,000
population. About 69 percent of the available beds are within 5 miles
of Charity and University hospitals, and about 91 percent are within 10
miles. Consequently, patients who live and work within Orleans Parish
are close to hospital services. Figure 1 shows the location of all the
hospitals in the greater New Orleans area, including the nine open
hospitals we surveyed.
Figure 1: Open and Closed Hospitals in the New Orleans Area as of June
2006:
[See PDF for image]
Source: GAO analysis of data provided by the hospitals in the greater
New Orleans area.
[A] Elmwood Medical Center is included on the map because it was
operating in June 2006. However, we did not include Elmwood in our
survey because it opened on April 24, 2006, and so data on available,
staffed, and occupied beds were not available for the month of April.
[B] Symbol placement for New Orleans VA Medical Center and Tulane
University Hospital & Clinic has been altered slightly for legibility
purposes.
[End of figure]
Furthermore, hospital officials we surveyed told us that they planned
to reopen additional staffed beds by the end of the year. For example,
LSU plans to reopen 166 beds at University Hospital in late September
or early October 2006 and an additional 224 beds by the end of the year
for a total of 390 additional staffed beds. Tulane University Hospital
and Clinic plans to reopen an additional 117 staffed beds by the end of
2006. In all, hospitals plan to reopen at least 674 staffed beds by the
end of 2006. Given these plans, even if the population of the greater
New Orleans area rises 30 percent by the end of 2006 over the estimated
population as of April 2006, there would be about 3.3 staffed beds per
1,000 population. This estimate assumes that the estimated population
of 588,000 in April 2006 would increase to 764,000 by December 2006.
Furthermore, the population of the greater New Orleans area would have
to increase by 325,000 or about 55 percent, to 913,000, by December
2006 before staffed beds per 1,000 population dropped to the national
average of 2.8.
Occupancy Rates Were Higher Than They Were before Hurricane Katrina,
but Staffed Beds Were Sufficient for All Types of Inpatient Care Except
Psychiatric Care:
Consistent with nationwide data on occupancy rates (occupied beds as a
percentage of staffed beds), information we received on estimated
occupancy rates from hospitals in the greater New Orleans area
demonstrated wide month-to-month fluctuations. Nevertheless, these
hospitals were able to meet the demand for inpatient care, with the
exception, in many cases, of psychiatric care.
Post-Hurricane Katrina hospital occupancy rates in the greater New
Orleans area are higher than they were before the hurricane. For all
types of care, eight of the nine hospitals we contacted provided us
with an estimated overall occupancy rate for the 9-month period
following the hurricane (through April 2006) and for the 12-month
period before the hurricane. The hospitals' occupancy rates for the 9-
month period after the hurricane ranged from 45 percent to 100 percent,
or an average of 77 percent, compared with a range from 33 percent to
85 percent, or an average of 70 percent, for the 12-month period before
the hurricane.[Footnote 17] The American Hospital Association reported
that the average monthly hospital occupancy rate nationwide was 67
percent in 2004, the most recent year for which nationwide data are
available.
We also obtained actual occupancy rate information from the nine
greater New Orleans area hospitals for one day--April 25, 2006--and
five of them[Footnote 18] provided actual daily occupancy rate
information for the entire month of April 2006. The five hospitals
reported actual occupancy rates that ranged from 70 percent to 89
percent (70, 75, 85, 86, and 89 percent).
According to hospital officials, the greatest need was for medical/
surgical care, adult critical care, and psychiatric care beds. For
example, on April 25, 2006, the occupancy rate was 95 percent for
medical/surgical care, 96 percent for adult critical care, and 100
percent for psychiatric care, compared with rates of 68 percent and 71
percent for obstetrics care and pediatrics care, respectively. (See
table 2.) Hospital officials also told us that inpatient psychiatric
care beds were frequently not available in the greater New Orleans area
and that psychiatric patients were the only type of patients that had
to be transferred out of the greater New Orleans area because of a lack
of beds. For example, an official at one hospital reported that since
Hurricane Katrina the demand for psychiatric services has overwhelmed
that hospital's 15-bed psychiatric unit, and the hospital has had to
house up to eight psychiatric patients in the emergency department at
one time until psychiatric beds could be found in other facilities. An
official at another hospital reported that sometimes psychiatric
patients have stayed in the emergency department for several days until
an inpatient psychiatric bed could be found for them somewhere else in
Louisiana. An official at a third facility stated that the facility's
case workers frequently spent all day calling other facilities in the
state looking for an inpatient psychiatric bed. In one case, workers
made 39 telephone calls before locating a facility that would accept
the patient.
Table 2: Number of Available, Staffed, and Occupied Beds by Type of
Care at Hospitals in the Greater New Orleans Area on April 25, 2006:
Type of care: Adult critical care;
Available beds: 320;
Staffed beds: 306;
Occupied beds: 295;
Percentage of occupied to staffed beds (occupancy rate): 96;
Percentage of occupied to available beds: 92.
Type of care: Medical/surgical care;
Available beds: 1,100;
Staffed beds: 895;
Occupied beds: 851;
Percentage of occupied to staffed beds (occupancy rate): 95;
Percentage of occupied to available beds: 77.
Type of care: Obstetrics;
Available beds: 165;
Staffed beds: 138;
Occupied beds: 94;
Percentage of occupied to staffed beds (occupancy rate): 68;
Percentage of occupied to available beds: 57.
Type of care: Pediatrics;
Available beds: 350;
Staffed beds: 262;
Occupied beds: 185;
Percentage of occupied to staffed beds (occupancy rate): 71;
Percentage of occupied to available beds: 53.
Type of care: Psychiatric care;
Available beds: 95;
Staffed beds: 57;
Occupied beds: 57;
Percentage of occupied to staffed beds (occupancy rate): 100;
Percentage of occupied to available beds: 60.
Type of care: Other (rehabilitation, skilled nursing care, etc.);
Available beds: 298;
Staffed beds: 220;
Occupied beds: 206;
Percentage of occupied to staffed beds (occupancy rate): 94;
Percentage of occupied to available beds: 69.
Type of care: Total;
Available beds: 2,328;
Staffed beds: 1,878;
Occupied beds: 1,688;
Percentage of occupied to staffed beds (occupancy rate): [Empty];
Percentage of occupied to available beds: [Empty].
Source: GAO analysis of data provided by the hospitals in the greater
New Orleans area.
[End of table]
Occupancy rates increased following Hurricane Katrina not only because
of the loss of staffed beds but also because patients on average have
been staying in the hospital longer. According to hospital officials,
the average length of stay has increased by about one-half day because
there is a shortage of facilities to which patients can be discharged,
such as skilled nursing facilities and long-term care facilities. In
addition, because of the extensive destruction of housing, many
patients may not have appropriate housing to which they can return.
According to a recent report prepared for the Louisiana Recovery
Authority Support Foundation, a single-day increase in the average
length of stay drives occupancy rates up about 15 percent.[Footnote 19]
Recruiting, Hiring, and Retaining Hospital Staff Posed Significant
Challenges:
Hospital officials reported that recruiting, hiring, and retaining
nurses and support staff, such as nursing aids, housekeepers, and food
service workers, to staff the available beds constituted a great
challenge. The officials told us that the demand for nurses was greater
than the supply because (1) many nurses left the greater New Orleans
area during and after the storm, (2) there was an insufficient supply
of suitable housing for nurses, and (3) local nurses were being
recruited by facilities outside the greater New Orleans area. According
to officials, the hospitals have been able to reopen beds and keep them
open by having employees work overtime and by paying higher salaries
for permanent and temporary contract staff. However, a shortage of
skilled workers remains. For example, an official at one hospital
reported that the hospital had to temporarily suspend its open heart
surgery program because of its inability to hire operating room nurses
and technicians with experience in open heart surgery, even after
offering a salary increase of over 30 percent. Officials also stated
that competition from nonhospital employers for unskilled workers made
it difficult for the hospitals to hire and retain them. For example,
whereas the average hourly rate for food service workers was about $7
per hour before Hurricane Katrina, fast food restaurants are currently
offering about $12 per hour, with one restaurant chain, for example,
offering a signing bonus of about $6,000.
Hospitals Reported High Demand for Emergency Department Services:
The hospitals that remained open after Hurricane Katrina have reported
a high demand for services in their emergency departments. Data
reported by some of the hospitals[Footnote 20] showed that wait times
for emergency medical service vehicles to move stable patients from the
vehicle into the emergency department varied from no wait time at one
hospital to almost 40 minutes at another hospital for the 30 days
between March 28 and April 26, 2006. During the same 30-day period,
four of these hospitals reported that their emergency departments were
occasionally at capacity and therefore temporarily diverted patients to
other facilities. The four emergency departments temporarily diverted
patients 8 to 26 times; three of the departments reported being in
diversionary status from 5 to 48 hours. Over this same period,
officials from six of the nine hospitals also reported that an average
of 7 patients per day had to be housed in the emergency department
until a hospital bed was available after a decision had been made to
admit them to the hospital.[Footnote 21] This ranged from 1 patient per
day at one hospital to 18 patients per day at another hospital.
By comparison, demand for emergency medical services in other parts of
the country is also high. For example, the Institute of Medicine
reported in June 2006 that emergency department crowding was a
nationwide problem, with numbers of visits having grown by 26 percent
from 1993 to 2003. The Institute of Medicine also reported that
patients are often boarded in the emergency department for 48 hours or
more until an inpatient bed became available.[Footnote 22] Furthermore,
an April 2002 report conducted for the American Hospital Association
found that officials at many hospitals in urban areas described their
emergency departments as operating at or above capacity.[Footnote 23]
In addition, we reported in March 2003 that because of a lack of
inpatient beds about 2 in 10 of the 1,489 hospitals we surveyed
temporarily diverted patients from their emergency department more than
10 percent of the time--or about 2.4 hours or more per day--and nearly
1 in 10 hospitals temporarily diverted patients from their emergency
department more than 20 percent of the time--or about 5 hours per
day.[Footnote 24] In our March 2003 report, hospital officials cited
economic reasons for the lack of inpatient beds, including financial
pressures and the inability to staff the available beds because of
difficulty in recruiting nurses or the increased cost of hiring
contract nurses. We also reported that for about 1 in 5 hospitals the
average time that patients remained in the emergency department after a
decision was made to admit them as inpatients or transfer them to other
facilities was 8 hours or more.
Steps Have Been Taken to Reopen University Hospital, but LSU Has No
Plans to Reopen Charity Hospital:
FEMA and LSU have prepared damage assessments and cost estimates for
University and Charity hospitals. FEMA's cost estimates for repairs at
Charity and University hospitals are considerably lower than LSU's
estimates. While repairs are under way to reopen portions of University
Hospital beginning this fall, as of July 2006, LSU had no plans to
reopen Charity Hospital. Rather, LSU intends to pursue the possibility
of building a new facility, in collaboration with VA. Meanwhile, LSU
has established temporary facilities to provide some of the hospital
functions previously provided by the two hospitals. For example, LSU
established the MCLNO Emergency Services Unit, which is located in a
former department store, and opened a trauma center at the Elmwood
Medical Center.
LSU's Cost Estimates for Repairing Charity and University Hospitals Are
Considerably Higher Than FEMA's Estimates:
LSU's cost estimates for repairing Charity and University hospitals are
considerably higher than FEMA's estimates. Shortly after Hurricane
Katrina struck the greater New Orleans area, LSU hired ADAMS Management
Services Corporation (ADAMS) to assess the condition of the two
hospitals. In addition to identifying safety and health issues with
respect to physical construction and deficiencies, ADAMS was tasked
with recommending specific corrective measures, including cost
estimates, to make it feasible to restore the hospitals to a usable
condition. ADAMS completed its assessment in November 2005.[Footnote
25] According to the ADAMS assessment, Charity and University
hospitals' structural systems, such as columns, beams, and flooring,
were in functional condition, although further testing would be
required to verify this condition. However, the mechanical, electrical,
and plumbing systems were beyond repair, and there were significant
environmental safety problems. ADAMS estimated the repair costs at
$257.7 million for Charity Hospital and $117.4 million for University
Hospital. ADAMS also estimated replacement costs at $395.4 million for
Charity Hospital and $171.7 million for University Hospital. On the
basis of these estimates, ADAMS determined that repair costs exceeded
50 percent of the replacement costs for the two hospitals. As a result,
LSU officials told us they believed that the hospitals met the Public
Assistance program criteria for replacement funding and that LSU could
obtain 90 percent of the estimated cost to replace Charity and
University hospitals through the Public Assistance program.
FEMA's cost estimates for repairing the two hospitals, however, are
considerably lower than LSU's estimates. FEMA completed its initial
damage assessment in December 2005. However, FEMA's initial assessment
did not include elevator repairs because the elevators were not
accessible at that time. FEMA completed its assessment of the elevators
in April 2006.[Footnote 26] Like the assessment ADAMS did for LSU,
FEMA's initial assessment found mechanical, electrical, and plumbing
damage, among other things. FEMA estimated the repair costs, including
the elevator repair costs, at $27 million for Charity Hospital and
$13.4 million for University Hospital. FEMA also estimated replacement
costs at $147.7 million to $267.3 million for Charity Hospital and
$57.4 million to $103.9 million for University Hospital. From these
estimates, FEMA determined that the repair costs did not exceed 50
percent of the replacement costs for the two hospitals. (See table 3
for a comparison of LSU's and FEMA's repair and replacement estimates.)
Table 3: LSU's and FEMA's Cost Estimates for Charity and University
Hospitals:
Charity Hospital: Repair estimate (in millions);
LSU's estimates: $257.7; [Empty];
FEMA's estimates: $27.
Charity Hospital: Replacement estimate (in millions);
LSU's estimates: $395.4; [Empty];
FEMA's estimates: $147.7 - $267.3.
Charity Hospital: Repair cost as a percentage of replacement estimate;
LSU's estimates: 65%; [Empty];
FEMA's estimates: 10% - 18%.
University Hospital: Repair estimate (in millions);
LSU's estimates: $117.4; [Empty]
FEMA's estimates: $13.4.
University Hospital: Replacement estimate (in millions);
LSU's estimates: $171.7; [Empty];
FEMA's estimates: $57.4 - $103.9.
University Hospital: Repair cost as a percentage of replacement
estimate;
LSU's estimates: 68%; [Empty];
FEMA's estimates: 13% - 23%.
Sources: ADAMS 2005 Emergency Facilities Assessment and FEMA Project
Worksheets.
Notes: FEMA also completed damage assessments for all buildings on the
Charity and University campuses, such as Charity's laundry building and
University's pediatrics emergency center. LSU's assessments did not
include all these buildings. Therefore, for comparison purposes, we
report only FEMA's and LSU's cost estimates for the main hospitals on
the University and Charity campuses. Significant factors contributing
to the differences between FEMA's and LSU's cost estimates are (1) the
scope of work included in the estimates and (2) whether a cost
escalator was used in developing the estimates.
[End of table]
Two significant factors contribute to the differences between LSU's and
FEMA's cost estimates. First, LSU's cost estimates cover whole building
repair, meaning that they include costs for damage from Hurricane
Katrina and many deficiencies that had been identified before the
hurricane. For example, LSU's estimates include costs for installing
fire-rated doors and frames in all exit corridors throughout University
Hospital, the lack of which was identified in 2003 as a problem that
needed to be addressed. In contrast, FEMA's estimates for Charity and
University hospitals cover the repair costs for damage from flooding
and wind only, since these are the only repair costs eligible for
federal reimbursement under the Public Assistance program. Prior
deficiencies are generally not eligible for reimbursement. Second,
LSU's estimates also included a 66 percent cost escalation over a
commonly used index of labor and material for New Orleans. The cost
escalation was meant to anticipate material and labor shortages over
the next 3 to 6 years as a result of the hurricane. FEMA's estimates,
in contrast, did not include a cost escalation for labor and material.
According to FEMA, three of the five bids for a recently awarded
contract for the New Orleans Arena were below the federal government
estimate. Based on those bids, FEMA concluded that a cost escalation
for labor and material inflation was not justified.
State officials disputed FEMA's cost estimates of the hurricane damage
to Charity and University hospitals. LSU maintained that these
hospitals are not repairable, as defined by federal regulation.
Specifically, LSU maintained that the cost of repairing the hospitals
to their predisaster condition exceeded 50 percent of the cost of
replacing the hospitals and that it was not feasible to repair the
hospitals so that they could perform the functions for which they were
being used immediately prior to the disaster. In a November 2005 letter
to Vice Admiral Thad Allen,[Footnote 27] LSU noted that "It is not
feasible to repair these facilities to restore the design, function,
and capacity, as well as all required code and standard upgrades, at a
reasonable cost." LSU further suggested in the letter that FEMA's
estimated costs were too low, noting that FEMA's estimates did not
include all eligible expenses that might be incurred in completing the
repairs, such as those associated with compliance with the Americans
with Disabilities Act (ADA). For example, the ADAMS assessment includes
accessibility upgrades to bring Charity and University hospitals into
compliance with current ADA requirements, including upgrades to the
restrooms, telephones, and drinking fountains. Officials from OFPC,
which administers the design and construction of all Louisiana state-
owned facilities damaged in Hurricane Katrina, also told us that FEMA's
estimates for the two hospitals were too low and did not reflect the
current market conditions (i.e., the shortage of labor and material).
Officials from both LSU and OFPC provided several examples of FEMA's
underestimating the costs of repairs for facilities in the greater New
Orleans area. For example, FEMA estimated the costs for repair to the
engineering building on the University of New Orleans campus at about
$286,000. The contract was awarded for about $689,000. However, FEMA
officials cautioned against using differences in estimated and actual
repair costs for other facilities as benchmarks for comparing or
adjusting the estimates for Charity and University hospitals, noting
that each facility and its associated estimate are unique.
To help reconcile FEMA's and LSU's cost estimates, FEMA officials
suggested that LSU select a few projects at Charity Hospital and put
them out for bid. According to FEMA officials, this process would
provide actual repair costs and could serve as a baseline for adjusting
LSU's or FEMA's estimates as needed. FEMA officials noted that some
repair projects at Charity Hospital would be necessary even if LSU
opted to replace, not repair, the facility. Officials from LSU and OFPC
told us that they questioned whether this would be the best use of time
and resources, however, especially since they said they did not believe
that restoring Charity Hospital to its predisaster condition would
adequately meet the health care needs of the community. However, a
senior OFPC official told us that OFPC would evaluate whether some
repairs were necessary to prevent further deterioration of the
facility.[Footnote 28]
FEMA has begun the process of obligating funds based on its
assessments. As of June 16, 2006, FEMA had obligated about $21.5
million for repairs to Charity Hospital and $14.3 million for repairs
to University Hospital. The funds are allocated to Louisiana's Office
of Homeland Security and Emergency Preparedness (i.e., the grantee),
which then distributes the funds to LSU (i.e., the applicant) for
reimbursement for the costs of repairing Charity and University
hospitals.
Repairs to University Hospital Are Under Way, and LSU Is Pursuing the
Possibility of a New Facility to Replace Both Charity and University
Hospitals in the Future:
At the time of our visit in May 2006, repairs to University Hospital
were under way, and portions of the facility were expected to reopen by
late September or early October 2006, with the remainder of the
facility expected to open by the end of the year. Initially, LSU
officials had hoped to reopen a portion of the facility by the end of
June 2006. However, according to LSU officials, estimates for reopening
a portion of the facility in June--which assumed a 75-day construction
schedule--were optimistic given the amount of repair work needed. An
official from OFPC told us that several contractors estimated it would
take 180 days to complete the work, which was more than 3 months longer
than LSU requested. LSU and the winning contractor ultimately
negotiated a 120-day construction schedule. According to this new
schedule, LSU plans to reopen portions of University Hospital,
including inpatient beds, a pharmacy, and a blood bank, in fall 2006.
In addition, LSU plans to convert space on the first floor of the
hospital for a Level I trauma center. This work is scheduled to be
completed by the end of 2006. However, officials from LSU and OFPC
stated that the schedule is subject to change, depending on the
availability of resources and the ability of the contractor to complete
the repair work on time.[Footnote 29] In addition, although LSU plans
for University Hospital to be fully operational by the end of the year,
a senior LSU official told us that LSU is pursuing the possibility of a
new hospital that would allow it to close University Hospital in the
future. According to this official, the building is near the end of its
useful life.
While repairs to University Hospital are under way, LSU currently has
no plans to reopen Charity Hospital. Charity Hospital sustained
significant damage as a result of Hurricane Katrina, in large part
because of the flooding that occurred in the basement. In addition,
according to officials from LSU and OFPC, the facility was antiquated
prior to Hurricane Katrina and was not well suited for a modern acute
care medical facility. As a result, LSU does not want to invest
significant resources in repairing the facility and would prefer to
invest available funding in constructing a replacement facility. If LSU
decides to replace Charity Hospital, LSU is authorized under the Public
Assistance program to use funds approved for repair, including the
$21.5 million already obligated, on a replacement facility. However,
the amount eligible for reimbursement cannot be greater than 90 percent
of FEMA's initial cost estimates for repairs.
Prior to Hurricane Katrina, LSU had decided to support the construction
of a new facility to replace both University and Charity hospitals, and
it was seeking funding for the project when the storm occurred. LSU
continues to support this option and has taken some initial steps, in
collaboration with VA, to plan for a new facility. Like LSU's Charity
and University hospitals, VA's New Orleans Medical Center sustained
extensive damage as a result of Hurricane Katrina, and VA has
determined that the existing facility is no longer suited for providing
patient care. As a result, VA is also proposing to construct a new
facility.[Footnote 30] LSU and VA formed the Collaborative
Opportunities Study Group (COSG) to study options for constructing a
new joint hospital facility. In its June 2006 report, COSG recommended
a "collaborative complex"--that is, separate VA and LSU bed towers
connected by a corridor that houses facilities and services used by
both entities. According to the June report, a collaborative complex
would be more cost-effective than LSU and VA operating stand-alone
facilities.[Footnote 31]
LSU Has Established Temporary Facilities to Provide Public Hospital
Functions:
Following Hurricane Katrina, LSU established several temporary
facilities in order to continue to meet the health care needs of the
population currently in the greater New Orleans area and to continue to
fulfill LSU's mission of providing care to the uninsured. Two key
temporary facilities are the MCLNO Emergency Services Unit and the
trauma center at the Elmwood Medical Center. The MCLNO Emergency
Services Unit is located in a former department store in downtown New
Orleans. It was originally established in the parking lot of University
Hospital in October 2005. The facility was moved to the Ernest N.
Morial Convention Center in November 2005 and eventually to its current
location in March 2006. According to LSU officials, the MCLNO Emergency
Services Unit provides a variety of outpatient services, including
minor emergency services, dental care, radiology services, and services
for victims of sexual assault, among others. According to LSU
officials, the facility is not equipped to provide major emergency
services. In order to accommodate the services being provided, LSU set
up cubicles and tents to serve as treatment rooms, storage, conference
rooms, and offices. LSU plans to close the MCLNO Emergency Services
Unit in October 2006, when University Hospital is reopened.
LSU is also leasing space for a trauma center from the Ochsner Clinic
Foundation at its Elmwood Medical Center. LSU opened the facility on
April 24, 2006, to provide the trauma services previously provided at
Charity Hospital. Charity Hospital served as the only Level I trauma
center in the region.[Footnote 32] According to LSU officials, the
trauma center at Elmwood Medical Center houses a blood bank,
laboratory, pharmacy, and treatment rooms, among other things. In
addition, computed tomography and magnetic resonance imaging services
are provided in mobile trailers on the grounds of the facility. LSU's
lease for this space expires at the end of 2006.
HHS Has Provided Financial and Technical Assistance and Program Waivers
to Help Address Restoration:
HHS officials said that the agency's efforts to restore hospitals'
health care infrastructure following Hurricane Katrina included
financial assistance, technical assistance, and waivers that allow
exceptions to some program requirements. HHS financial assistance
included two opportunities for hospitals to receive additional funds
for infrastructure repair--SSBG[Footnote 33] that may be used to repair
or rebuild health care facilities, and a Medicare extraordinary
circumstances exception that allows damaged hospitals to receive
payment for capital costs. SSBG funds generally cannot be used for
construction; however, the Department of Defense, Emergency
Supplemental Appropriations to Address Hurricanes in the Gulf of
Mexico, and Pandemic Influenza Act, 2006, enacted December 30, 2005,
specifically authorized the use of SSBG funds appropriated by that act
for the repair, renovation, and construction of health
facilities.[Footnote 34] The act appropriated an additional $550
million to the SSBG program, from which HHS designated about $221
million for Louisiana in February 2006.
In addition, four applications were submitted to CMS for assistance to
hospitals in the greater New Orleans area under the Medicare
extraordinary circumstances exception, which provides additional
payments for unanticipated capital expenditures that exceed $5 million
(after taking into account proceeds from other sources, such as
insurance or FEMA aid) and result from extraordinary circumstances,
such as hurricanes. The provision does not provide a lump sum payment
up front; instead, it allows eligible hospitals that serve Medicare
patients to depreciate the cost of the unanticipated capital
expenditures over the life of the asset, once repairs have been
made.[Footnote 35] Charity and University hospitals (submitting a joint
application), East Jefferson General Hospital, Tulane University
Hospital and Clinic, and Ochsner Medical Center have applied for this
funding. As part of the approval process, HHS requested that each
hospital provide a plan and a schedule for submission of documents to
support its exception request. As of June 8, 2006, only Charity and
University hospitals had provided estimates of their expected capital
expenditures, which they set at approximately $900 million, an HHS
official said.
HHS technical assistance to Louisiana related to restoration of the
health care infrastructure includes both ongoing and planned technical
assistance.[Footnote 36] Since Hurricane Katrina, HHS has assigned
staff members to assist hospitals and other state and local entities in
Louisiana in evaluating health care challenges and identifying
available resources. For example, HHS staff members did the following:
* Provided consultation services at Orleans Parish health planning
committee meetings that addressed shortages of staff, hospital beds,
and funding. As a result, an immediate need for registered nurses was
identified, and HHS, in coordination with VA, made arrangements for 12
to 20 registered VA nurses on 2-to 4-week rotations through mid-April
2006 to provide emergency room, medical-surgical, and intensive care
unit services at Tulane University Hospital and Clinic.
* Conducted joint weekly teleconferences beginning in January 2006 with
the Joint Commission on Accreditation of Healthcare Organizations,
state survey agencies, and hospital and other health care providers to
coordinate the application of accreditation standards for hospitals
that were providing care in temporary facilities or in facilities
damaged by the hurricanes.
* Facilitated meetings between St. Bernard Parish and a nonprofit
medical center that led to the opening of a new primary and urgent care
facility in April 2006 after the parish lost all its health care
facilities during Hurricane Katrina.
Additionally, since Hurricane Katrina, HHS officials have chaired two
federal interagency working groups, the President's Health Care:
Chronic Care and Facilities Restoration Workgroup and HHS's Gulf Coast
Recovery Working Group. The President's Health Care: Chronic Care and
Facilities Restoration Workgroup produced two major working papers in
2006, a summary of the federal payments available for providing health
care services and rebuilding health care infrastructure after Hurricane
Katrina and a document that sets out guiding principles for the federal
government in the rebuilding process.[Footnote 37] The federal payments
summary served as the basis for two all-day interagency workshops in
New Orleans on January 10, 2006, and February 9, 2006, sponsored by HHS
and Louisiana, for local and regional health care providers and elected
officials to identify information about available federal resources and
to provide technical assistance in accessing them. While the
President's Health Care: Chronic Care and Facilities Restoration
Workgroup has disbanded, many of its members have been included in
meetings of the Gulf Coast Recovery Working Group. The Gulf Coast
Recovery Working Group is an HHS staff-level group that meets regularly
to resolve issues and offer advice on how to improve HHS programs
supporting the recovery efforts. The Gulf Coast Recovery Working Group
also began working with the Department of Homeland Security's Office of
the Federal Coordinator for Gulf Coast Rebuilding shortly after the
office was established on November 1, 2005, by Executive Order 13390 to
lead the federal response.[Footnote 38] The Gulf Coast Recovery Working
Group reports to the HHS Secretary and provides input to, and
coordinates on a policy level with, the Federal Coordinator.
Planned technical assistance is part of a broader effort to redesign
the entire continuum of Louisiana's health care delivery system, from
primary care clinics to the restoration of hospital inpatient care and
emergency department services in the greater New Orleans area, HHS
officials said. HHS plans to provide technical assistance to the
Louisiana Healthcare Redesign Collaborative (Collaborative), a state
and locally led effort to redesign the health care delivery system in
Louisiana, including the existing hospital system.[Footnote 39] HHS's
Office of the Secretary expects to provide technical staff, guidance,
and funds to support the redesign effort. In an address before the
Louisiana state legislature on April 25, 2006, the Secretary of HHS
committed to participating in the redesign effort but emphasized that
the redesign effort must be locally led and governed according to
guiding principles endorsed by all participants. A charter, signed July
17, 2006, places the Collaborative under the authority of the Louisiana
Department of Health and Hospitals and includes guiding principles. To
help coordinate technical assistance from HHS to the Collaborative, HHS
has hired a full-time senior advisor to the Secretary of HHS and plans
to provide part-time staff from across HHS agencies. HHS officials said
that the agency expected to work with the Collaborative to develop a
health care system recovery proposal that could include requests for
Medicare demonstrations and Medicaid waivers.[Footnote 40] HHS
officials said that they expected that the redesign effort would
produce a more efficient and effective health care delivery system in
Louisiana. HHS officials noted that prior to Hurricane Katrina,
Louisiana had one of the most expensive health care systems in the
United States, but that it generally ranked close to the bottom among
states in terms of health care quality indicators.
The Secretary of HHS has waived or modified various statutory and
regulatory requirements to assist hospitals and other health care
providers in states in which he had declared a public health emergency.
For example, certain Medicare billing and other requirements were
waived or modified to accelerate Medicare payments in the hurricane-
affected states, including Louisiana. Under the waivers, HHS has:
* paid hospitals the inpatient acute care rate for Medicare patients
that remained in a hospital but no longer required acute level care,
until the patient could be discharged to an appropriate facility;
* relaxed the data requirements to substantiate payment to the provider
when a facility's records were destroyed;
* allowed hospitals to have a responsible physician (e.g., the chief of
medical staff or department head) sign an attestation of services
provided when the attending physician could not be located; and:
* instructed its payment processing contractors to immediately process
requests for accelerated payments for health care providers, including
hospitals, affected by the hurricane.
In addition, after HHS received inquiries concerning whether hospitals
could provide free office space, low interest or no interest loans, or
other arrangements to assist physicians displaced by Hurricane Katrina,
the Secretary permitted CMS to waive sanctions for violations of the
physician self-referral prohibition, known as the Stark Law,[Footnote
41] through January 31, 2006. This time-limited relief concerns
statutory prohibitions against a physician referring Medicare patients
to an entity with which the physician or a member of the physician's
immediate family has a financial relationship. HHS officials said that
a waiver had been approved for one hospital in the greater New Orleans
area for one physician.
HHS officials said that few HHS programs or activities are designed to
help address the restoration of hospital inpatient care and emergency
department services in the greater New Orleans area. The department
does not have broad authority to respond to the needs of hospitals
affected by a disaster, HHS officials said. They cited several issues
that limit the agency's ability to provide this type of assistance.
First, agency officials emphasized that HHS's role in financing health
care services does not easily translate into providing restoration
assistance after a disaster. Second, HHS must consider whether proposed
responses to problems identified in the greater New Orleans area could
adversely affect other areas of the country. For example, Louisiana has
requested that HHS adjust the wage index used in determining Medicare
prospective payments to hospitals to account for the higher wages that
must be paid to attract or maintain health care workers, including
nurses and physicians, in the greater New Orleans area. However, HHS
officials said that by law, changes to the wage index must be "budget
neutral." Practically, this means that if the wage index is increased
for the greater New Orleans area, then the wage index must be decreased
for another area, HHS officials said.
Agency Comments:
We sent a draft of this report for comment to DHS, HHS, VA, and the
State of Louisiana. Excerpts from it were also sent to LSU for comment.
HHS agreed with the draft report, and its comments are included as
appendix II. VA informed us by e-mail that it agreed with the draft
report. DHS also responded by email and informed us that it had no
formal comments on the draft report. DHS, HHS, and VA also provided
technical comments, as did Louisiana's Department of Health and
Hospitals through an e-mail response. We considered all technical
comments and incorporated those that were appropriate. LSU did not
provide comments.
We are sending copies of this report to the Secretaries of Homeland
Security, Health and Human Services, and Veterans Affairs and other
interested parties. We will also make copies available to others on
request. In addition, the report is available at no charge on the GAO
Web site at http://www.gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this report.
If you or your staffs have any questions about this report, please
contact Cynthia Bascetta at (202) 512-7101 or bascettac@gao.gov for
issues related to health services. Please contact Terrell G. Dorn at
(202) 512-6923 or dornt@gao.gov for issues related to medical
facilities and FEMA. GAO staff members who made significant
contributions to this report are listed in appendix III.
Signed by:
Cynthia A. Bascetta:
Director, Health Care:
Signed by:
Terrell G. Dorn, PE:
Director, Physical Infrastructure:
List of Congressional Committees:
The Honorable Susan M. Collins:
Chairman:
The Honorable Joseph I. Lieberman:
Ranking Minority Member:
Committee on Homeland Security and Governmental Affairs:
United States Senate:
The Honorable Charles E. Grassley:
Chairman:
Committee on Finance:
United States Senate:
The Honorable Michael B. Enzi:
Chairman:
The Honorable Edward M. Kennedy:
Ranking Minority Member:
Committee on Health, Education, Labor and Pensions:
United States Senate:
The Honorable Daniel K. Akaka:
Ranking Minority Member:
Committee on Veterans' Affairs:
United States Senate:
The Honorable Thomas M. Davis:
Chairman:
The Honorable Henry A. Waxman:
Ranking Minority Member:
Committee on Government Reform:
House of Representatives:
The Honorable Bennie G. Thompson:
Ranking Minority Member:
Committee on Homeland Security:
House of Representatives:
The Honorable John D. Dingell:
Ranking Minority Member:
Committee on Energy and Commerce:
House of Representatives:
The Honorable Lane Evans:
Ranking Minority Member:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable Nancy L. Johnson:
Chairman:
Subcommittee on Health:
Committee on Ways and Means:
House of Representatives:
[End of section]
Appendix I: Scope and Methodology:
To examine the availability of hospital inpatient care and the demand
for emergency department services, we contacted nine operating public
and private hospitals in the greater New Orleans area.[Footnote 42] We
randomly selected one day--April 25, 2006--and asked hospital officials
to provide information on the number of available, staffed, and
occupied beds[Footnote 43] for that day, by type of patients served,
such as critical care, medical and surgical, and pediatrics. We later
asked for the number of available, staffed, and occupied beds for the
entire month of April; however, only five hospitals responded to this
request. From the hospital officials we also obtained estimates of the
occupancy rates for the 12-month period prior to, and the 9-month
period following, Hurricane Katrina for 8 of the 9 open hospitals. We
weighted the estimated hospital occupancy rates by the number of
staffed beds to obtain a weighed average. Further, we asked about plans
to open more beds and about emergency department services provided for
the 30-day period from March 28, 2006, through April 26, 2006.[Footnote
44] We conducted telephone interviews with senior officials from seven
of the nine hospitals to clarify information provided in their written
responses to our survey.[Footnote 45] We did not independently verify
the data the hospitals provided on bed availability and the amount of
emergency care provided. To determine the April 2006 population of the
four parishes in the greater New Orleans area, we used estimates from
the Louisiana Department of Health and Hospitals Bureau of Primary Care
and Rural Health, which used two methodologies to estimate the
population in each of the parishes. It used school enrollment data for
Jefferson, St. Bernard, and Plaquemines parishes; and for Orleans
Parish it used a survey of persons occupying residential structures.
The survey had been conducted by the New Orleans Health Department in
consultation with the Centers for Disease Control and Prevention. We
limited our work to examining the status of hospital inpatient and
emergency departments in the greater New Orleans area and did not
examine other aspects of hospital services, such as outpatient services
or the financial condition of the hospitals. We also did not address
other issues related to the health care system, such as the status of
primary care, medical research, or graduate medical education.
To examine the Federal Emergency Management Agency (FEMA) and Louisiana
State University (LSU) efforts to reopen Charity and University
hospitals,[Footnote 46] we reviewed LSU and FEMA damage assessments and
cost estimates for the facilities, FEMA regulations and guidance, and
the Department of Veterans Affairs' (VA) damage assessment of its
medical center in New Orleans. We toured Charity and University
hospitals and the temporary facilities LSU has established to provide
hospital outpatient care and emergency department services. We
interviewed officials from FEMA; LSU (including LSU's Health Care
Services Division that manages the public hospitals in the greater New
Orleans area); VA because it is considering building a joint hospital
complex with LSU in New Orleans; the Louisiana Recovery Authority
because it is the planning and coordinating body that was created in
the aftermath of Hurricane Katrina by the Governor of Louisiana to plan
for recovery and rebuilding efforts; and Louisiana's Office of Facility
Planning and Control because it is administering the design and
construction of all Louisiana state-owned facilities damaged by
Hurricane Katrina. We did not independently verify the damage
assessments prepared by FEMA and LSU. We limited our review to the
efforts to restore state-owned public hospital facilities.
To determine the activities that the Department of Health and Human
Services (HHS) has undertaken to help hospitals recover in the greater
New Orleans area, we interviewed officials in various HHS agencies,
including officials in the Centers for Medicare & Medicaid Services
headquarters and Dallas and Atlanta regional offices, the Health
Resources and Services Administration, the Administration for Children
and Families, and the Office of Public Health Emergency Preparedness.
Additionally, we reviewed documents and summaries outlining HHS
programs and activities related to helping restore hospital inpatient
care and emergency department services after a disaster. Finally, we
reviewed applicable federal law and regulations.
We conducted our work from April 2006 through September 2006 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix II: Comments from the Department of Health and Human Services:
Department Of Health & Human Services:
Office of the Assistant Secretary for Legislation:
Washington, D.C. 20201:
SEEP 12 2006:
Ms. Cynthia A. Bascetta:
Director, Health Care:
U.S. Government Accountability Office:
Washington, DC 20548:
Dear Ms. Bascetta:
Enclosed are the Department's comments on the U.S. Government
Accountability Office's (GAO) draft report entitled, "Status of
Hospital Inpatient Care and Emergency Department Services in the
Greater New Orleans Area" (GAO-06-1003), before its publication.
These comments represent the tentative position of the Department of
Health and Human Services and are subject to reevaluation when the
final version of this report is received.
The Department appreciates the opportunity to comment on this draft
report before its publication.
Sincerely,
Signed by:
Vincent J. Ventimiglia, Jr.
Assistant Secretary for Legislation:
Comments Of The Department Of Health And Human Services On The U.S.
Government Accountability Office's (GAO) Draft Report "Status Of
Hospital Inpatient Care And Emergency Department Services In The
Greater New Orleans Area" GAO 06-1003:
We have carefully reviewed your report and are pleased that GAO has
recognized the many efforts of the Department of Health and Human
Services (HHS) in providing financial and technical assistance to the
state and region. The Report specifically references a few of the many
efforts since the Hurricane, many of which continue today. In addition
to the $221 million in Social Services Block Grant funds specifically
mentioned in the Report, CMS has also provided $768.9 million to
Louisiana thus far for Medicaid and other health care costs. A new
Medicaid Section 1115 demonstration waiver was developed that allowed
Louisiana evacuees to quickly receive Medicaid coverage in their host
states and provided funds to Louisiana and other significantly impacted
States for the costs of care for victims with no health coverage. CMS
also used existing authority to provide flexibility in many Medicare
billing requirements, ensuring that providers continue to receive
Medicare payments. CMS has extensively coordinated its health care
quality assurance activities with State authorities and accrediting
organizations to facilitate the reestablishment of acute care services.
Secretary Michael O. Leavitt has personally been involved in creating a
vision to not only restore, but improve Louisiana's health care
delivery system that can be a model for the Nation. There were many
problems and imbalances in the New Orleans health care system for
decades prior to Hurricane Katrina's destruction. The Secretary has
challenged HHS at all levels to work with Louisiana officials to
establish a collaborative process for creating a new, cost-effective,
and quality health care model, based on guiding principles emphasizing
personal responsibility from all citizens, use of electronic
communications, full accessibility to coordinated, community-based,
patient-centered care, taking into account the Medicare, Medicaid, and
uninsured populations, and which considers an all-hazards approach for
effective emergency preparedness.
To further demonstrate his support for the collaboration between the
Department and LA, Secretary Leavitt has not only appointed a fulltime
Senior Advisor for this rebuilding effort, but has supplied eight full
time HHS staff --four have been out-stationed to Louisiana and four to
HHS Headquarters to facilitate development of the comprehensive
Medicaid waiver and Medicare demonstration proposal.
The Report makes an important finding that even after a number of major
hospitals have been closed due to Hurricane Katrina, the number of
staffed and available beds in the greater New Orleans area is still
above the national average.
We agree there are sufficient numbers of staffed hospital inpatient
beds in the greater New Orleans area. GAO notes that demand for
psychiatric care is an exception to this finding. The GAO report
indicates that psychiatric and emergency department patients are
currently underserved in the New Orleans area. These challenges are
long term in nature and require sustained collaboration among local,
State and Federal governments, together with both for-profit and non-
profit providers.
We also agree with your findings that a major challenge in restoring
quality health care to the greater New Orleans area is success in the
recruitment of sufficient trained and qualified health care workers
(e.g., physicians, pharmacists, psychiatrists, nurses, therapists,
social workers, nurse aides and other direct care workers, etc.) in all
areas of health care. Currently, hospital stays are longer because
there are limited community alternatives.
We believe Louisiana and New Orleans will be better prepared for future
emergencies with a health care system that is not as dependent on
institutionally-based care as it has been in the past. Supporting
excess capacity in institutional care has inhibited adoption of
community-based and person centered care. We are pleased to be part of
Secretary Leavitt's efforts to assist Louisiana and New Orleans in
creating a modern health care system that will meet the needs of all of
their citizens.
[End of section]
Appendix III: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Cynthia A. Bascetta (202) 512-7101 or bascettac@gao.gov Terrell G. Dorn
(202) 512-6923 or dornt@gao.gov:
Acknowledgments:
In addition to the contacts named above, key contributors to this
report were Michael T. Blair, Jr., Assistant Director; Nikki Clowers,
Assistant Director; Karen Doran, Assistant Director; Jonathan Ban;
Michaela Brown; Nancy Lueke; Roseanne Price; and Cherie Starck.
FOOTNOTES
[1] For this report, we define the greater New Orleans area as
Jefferson, Orleans, Plaquemines, and St. Bernard parishes.
[2] While part of the statewide LSU public hospital system, Charity and
University hospitals are the two facilities that make up the Medical
Center of Louisiana at New Orleans (MCLNO). MCLNO, through these
hospitals and other facilities, is a primary provider of care to the
uninsured population in New Orleans.
[3] The National Response Plan establishes a comprehensive all-hazards
approach to enhance the ability of the United States to manage domestic
incidents. It establishes a framework of how the federal government
coordinates with state, local, and tribal governments and the private
sector during incidents.
[4] See GAO, Hurricane Katrina: Status of the Health Care System in New
Orleans and Difficult Decisions Related to Efforts to Rebuild It
Approximately 6 Months after Hurricane Katrina, GAO-06-576R
(Washington, D.C.: Mar. 28, 2006).
[5] Other factors include, for example, availability of housing, food,
schools, and transportation.
[6] See 31 U.S.C. § 717(b)(1).
[7] Acute care hospitals treat individuals whose illnesses or health
problems are short-term or episodic in nature.
[8] Available beds are beds that are licensed, set up, and available
for use. These are beds regularly maintained in the hospital for
patient use with supporting services, such as food, laundry, and
housekeeping. Available beds may or may not be staffed. Staffed beds
are available beds for which staff are on hand to attend to patients
who occupy the beds. Staffed beds may or may not be occupied. Occupied
beds are staffed beds that are being used by patients.
[9] Ten hospitals were operating as of June 30, 2006, but we did not
include one of them, Elmwood Medical Center, in our survey of
available, staffed, and occupied beds because it is a temporary
facility that was open for only 7 days in April and therefore data were
not available for the entire month.
[10] Trauma centers are designated based on resources and expertise to
treat injuries of differing types and levels of severity. Level I
trauma centers are able to treat any type of injury, no matter how
severe. According to the American College of Surgeons, a Level I trauma
center has a full range of specialists and equipment available 24 hours
a day and admits a minimum required annual volume of severely injured
patients.
[11] Robert T. Stafford Disaster Relief and Emergency Assistance Act
(as renamed by The Disaster Relief and Emergency Assistance Amendments
of 1988, Pub. L. No. 100-707, § 102(a), 102 Stat. 4689), Pub. L. No. 93-
288, § 406(c)(1)(B), 88 Stat. 143 (1974) (codified as added and amended
at 42 U.S.C. § 5172(c)(1)(B) (2000).
[12] 44 C.F.R. § 206.226(f) (2005).
[13] By way of comparison, Medicare requires that commonly used
services provided by managed care organizations must be available
within 30 minutes of driving time.
[14] American Hospital Association, Hospital Statistics 2006 Edition,
2006 Health Forum LLC. Used with permission. While the national average
was reported in 2006 by the American Hospital Association, it is based
on 2004 data, which is the most recent year for which nationwide data
are available.
[15] PricewaterhouseCoopers, Report on Louisiana Healthcare Delivery
and Financing System (2006). This report was prepared for the Louisiana
Recovery Authority Support Foundation. Used with permission.
[16] Louisiana Department of Health and Hospitals population estimates
for the four parishes reported by the Greater New Orleans Community
Data Center, Post Katrina Population & Housing Estimates (June 8,
2006).
[17] While officials at the ninth hospital reported information on the
number of available, staffed, and occupied beds, they did not provide
information on occupancy rates.
[18] The five are Children's Hospital, Ochsner Medical Center,
Meadowcrest Hospital, Touro Infirmary, and West Jefferson Medical
Center.
[19] PricewaterhouseCoopers, Report on Louisiana Healthcare Delivery
and Financing System.
[20] We obtained information on emergency room wait times for 6
hospitals and the number of times that 8 hospitals diverted patients to
other facilities for the 30-day period from March 28, 2006, through
April 26, 2006.
[21] Two hospitals did not house any patients in their emergency
departments. The remaining hospital did not answer the question on this
topic.
[22] Institute of Medicine of the National Academies, Future of
Emergency Care: Hospital-Based Emergency Care at the Breaking Point
(Washington, D.C.: June 2006).
[23] The Lewin Group, Emergency Department Overload: A Growing Crisis;
The Results of the AHA Survey of Emergency Department (ED) and Hospital
Capacity (Falls Church, Va.: April 2002).
[24] See GAO, Hospital Emergency Departments: Crowded Conditions Vary
among Hospitals and Communities, GAO-03-460 (Washington, D.C.: Mar. 14,
2003).
[25] According to LSU officials in May 2006, this assessment, including
the cost estimates, has not changed.
[26] FEMA also completed damage assessments for all buildings on the
Charity and University campuses, such as Charity's laundry building and
University's pediatrics emergency center. FEMA's rationale for
assessing these buildings is that they are needed to completely restore
Charity and University services. LSU's assessments did not include all
these buildings. Therefore, for comparison purposes, we report only
FEMA's and LSU's cost estimates for the main hospitals on the
University and Charity campuses.
[27] Vice Admiral Allen was the Federal Coordinating Officer for FEMA
at the Joint Field Office in Baton Rouge. As of May 25, 2006, he
assumed the duties of Commandant of the U.S. Coast Guard.
[28] Although state officials dispute FEMA's cost estimates, LSU did
not file an appeal. According to FEMA guidance, applicants, such as
LSU, may appeal FEMA's decisions regarding the provision of assistance,
such as FEMA's cost estimates, to FEMA. The applicant (i.e., LSU) must
file its appeal with the state within 60 days of receipt of a notice of
the action that is being appealed. In turn, the state has a limited
amount of time to review the appeal and submit a recommendation on the
merits of the appeal to FEMA. 42 U.S.C. § 5189a(a)(2000). According to
a FEMA official, FEMA considers the notice of action the date federal
obligations begin. Federal obligations for University and Charity
hospitals started this spring, and therefore the 60-day window for
appeal has expired.
[29] To encourage the timely completion of work, LSU's contract
includes a provision for $1,800-per-day payment by the contractor for
each calendar day past the scheduled completion date.
[30] The Emergency Supplemental Appropriations Act for Defense, the
Global War on Terror, and Hurricane Recovery, 2006 provided VA with an
additional $585.9 million for the construction of major projects for
necessary expenses related to the consequences of Hurricane Katrina and
other hurricanes of the 2005 season. Pub. L. No. 109-234, 120 Stat.
418, 468. Portions of this funding could be used for a new VA medical
center in New Orleans.
[31] The COSG report also recognized key issues and challenges that
must be addressed for the joint venture between LSU and VA to move
forward, such as VA's obtaining authorizing legislation. In our April
2006 report that examined the proposed joint ventures between VA and
its medical affiliates in Charleston and Denver, we also identified
potential challenges with such partnerships, including institutional
differences between VA and its medical affiliates and balancing funding
priorities. See GAO, VA Health Care: Experiences in Denver and
Charleston Offer Lessons for Future Partnerships with Medical
Affiliates, GAO-06-472 (Washington, D.C.: Apr. 28, 2006).
[32] According to a senior LSU official, LSU's trauma center at the
Elmwood Medical Center does not have Level I status because it is
considered a temporary facility.
[33] SSBG funds are allocated to the 50 states, the District of
Columbia, the Commonwealth of Puerto Rico, and the territories of Guam,
American Samoa, the Virgin Islands, and the Northern Mariana Islands to
furnish social services best suited to meet the needs of the
individuals residing within the jurisdiction. Jurisdictions receive
block grants and determine what services are provided, the eligible
categories and populations of adults and children, the geographic areas
of the jurisdiction in which each service will be provided, and whether
the services will be provided by jurisdiction, state, or local agency
staff or through grants or contracts with private organizations. 42
U.S.C. §§ 1397 et seq. (2000).
[34] Pub. L. No. 109-148, 119 Stat. 2680, 2768.
[35] For most hospitals, the payments under the extraordinary
circumstances exception are based on 85 percent of Medicare's share of
allowable capital costs attributed to the extraordinary circumstance.
If approved by CMS, the qualifying hospitals will receive funds for
extraordinary capital expenditures, based on a formula that considers
such things as each hospital's normal payments through the Medicare
Prospective Payment System. Qualifying hospitals request the
depreciation payments on their Medicare cost reports after the repairs
have been made.
[36] HHS does not have a separate budget for technical assistance.
Generally, the cost of technical assistance activities was absorbed by
the various agencies within HHS, an official said.
[37] The documents are Summary of Federal Payments Available for
Providing Health Care Services to Hurricane Evacuees and Rebuilding
Health Care Infrastructure and Federal Principles for Rebuilding the
Healthcare Infrastructure in the Gulf States.
[38] The executive order referred to this position as Coordinator of
Federal Support for the Recovery and Rebuilding of the Gulf Coast
Region.
[39] In June 2006 the Louisiana Legislature approved House Concurrent
Resolution No. 127, creating the Louisiana Healthcare Redesign
Collaborative to serve as an advising body to the Secretary of the
Department of Health and Hospitals for the development of
recommendations and plans for the redesign of the greater New Orleans
area health care system.
[40] CMS conducts and sponsors Medicare demonstration projects to test
and measure the effect of potential program changes. Demonstrations
study the likely impact of new methods of service delivery, coverage of
new types of services, and new payment approaches on beneficiaries,
providers, health plans, states, and the Medicare trust fund. Medicaid
waivers allow states flexibility in operating Medicaid programs and
include waivers that test policy innovations or that allow states to
implement managed care delivery systems.
[41] 42 U.S.C. § 1395nn (2000).
[42] Ten hospitals were operating at the time of our study, but we did
not include Elmwood Medical Center in our survey because it is a
temporary facility that opened on April 24, 2006, after our survey
began.
[43] Available beds are beds that are licensed, set up, and available
for use. These are beds regularly maintained in the hospital for
patient use with supporting services, such as food, laundry, and
housekeeping. Available beds may or may not be staffed. Staffed beds
are available beds for which staff are on hand to attend to the
patients who occupy the beds. Staffed beds may or may not be occupied.
Occupied beds are staffed beds that are being used by patients.
[44] We obtained information on emergency room wait times for 6
hospitals and the number of times that 8 hospitals diverted patients to
other facilities for the 30-day period from March 28, 2006, through
April 26, 2006.
[45] Officials from two of the hospitals did not respond to our request
for an interview.
[46] While part of the statewide LSU public hospital system, Charity
and University hospitals make up the Medical Center of Louisiana at New
Orleans.
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Washington, D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm
E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Public Affairs:
Jeff Nelligan, managing director,
NelliganJ@gao.gov
(202) 512-4800
U.S. Government Accountability Office,
441 G Street NW, Room 7149
Washington, D.C. 20548:
