Clinically Speaking

Five years after the storm, New Orleans' medical system is still in flux — but new models of delivering care may be an unexpected boon to patients


Eboni Price was born at Charity Hospital. Her parents met there. She drove her mother to work there. The Tulane Avenue landmark, where many of Louisiana's doctors were trained and countless New Orleanians — particularly the uninsured and underinsured — were treated, is very much a part of Price's history.

  Today, Price — now Dr. Eboni Price — sees patients in a small clinic on Rampart Street sandwiched between the French Quarter and Treme.

  Like po-boy shops and sno-ball stands, more than 85 community health clinics dot the metro area's landscape. The centers, understated compared with Charity, are taking in some of the same types of patients: construction workers, waitresses, shrimpers, the unemployed.

  Yet there is a stark difference in the type of medicine practiced, according to local health care advocates. With the expansion of primary care into neighborhoods following Hurricane Katrina, there has been a greater focus, from both doctors and patients, on preventing and managing disease.

  "The bottom line is that if you don't have timely access to care, then your default is going to be to use the emergency room," Price says.

Price arrived back in New Orleans in July 2005 after finishing her medical training and then a master's in public health from Johns Hopkins University. She began work at Tulane University School of Medicine. "My job was to oversee the outpatient training, and at the time, their outpatient training was all hospital-based," Price says. Then Katrina hit and the levees failed, and everything was turned upside down — or so it seemed. With hospitals flooded, street-corner clinics were set up. Price opened shop on Rampart Street, basing a clinic at Covenant House, a shelter for homeless youth, but seeing patients from all over the city. Within the first month, Price says, she began to see the long-term opportunities. Five years later, she sees the transformation: Patients are keeping appointments. They expect to see the same doctor they had before. And their health is improving.

  "We have proof of it," Price says. "We have folks who knew their diabetes, for instance, was poorly controlled or that their blood pressure wasn't controlled, and they skipped medications or did not take medications because they prioritized other things, but once they had a consistent provider to tell them why it was important and to help them pay for their medications. ... It was a whole different view of chronic disease management, from the patient's standpoint."

  Earlier this year, weeks before Louisiana State University medical students were due to submit their top picks for residency programs, Gov. Bobby Jindal reaffirmed the state's commitment to building a teaching hospital to replace LSU-owned Charity.

  The commitment appears to be the catalyst for keeping LSU's up-and-coming doctors at home, says Dr. Larry Hollier, chancellor of LSU Health Sciences Center New Orleans.

  "As Charity Hospital declined over the last 15 years, we saw a decrease in the number of students choosing to stay and train here," Hollier says. "Student residents who train tend to stay within proximity of the place in which they train. So it was very important to us (that) we get a teaching place that was adequate, that was attractive to them."

  The quality of medicine at Charity was good, Hollier says, but a squeeze on patient volume and the dated facility were turnoffs. "If you're training to be a urologist, would you really want to train in an institution that didn't have robotics?" he asks.

  The plan is to build the $1.2 billion University Medical Center next to a new Veterans Administration (VA) hospital between Canal Street and Tulane Avenue in lower Mid-City. Ground has yet to be broken, yet it has attracted much attention and controversy. Preservationists have decried abandoning Charity in favor of neighborhood encroachment, there have been clashes between LSU and Tulane over UMC's management, and complete funding has yet to be secured.

  The state has set aside nearly $475 million from FEMA and another $300 million in capital outlay funds for the project. It expects a newly formed UMC medical corporation to issue almost $425 million in bonds for the rest. The hospital, which will be owned by LSU, is expected to be open in 2014 with 424 beds, according to the state

  There are no plans right now for the existing Charity building, which has been shuttered since 2005.

  "What I'm afraid is going to happen is they're going to spend all this money ... and have a 70-acre parking lot with no money to build a hospital," says Jonah Evans, founder of the website, which advocates gutting and rebuilding the existing Charity Hospital. "The cooperation doesn't seem to be there for them to pull this off."

In the aftermath of Katrina, all nine Orleans Parish hospitals with emergency departments, including Charity and its sister campus University Hospital — now Interim LSU Public Hospital — were shut down due to flooding or lack of utilities. Children's Hospital and Touro Infirmary, which suffered minimal damage, were able to reopen quickly, but were the only two hospitals in the parish for about a year. Next Tulane Medical Center opened. The emergency room at Ochsner Baptist Medical Center on Napoleon Avenue reopened last year, though the hospital is a much smaller version of what it once was.

  Meanwhile, Lindy Boggs Hospital in Mid-City was purchased with plans to turn it into a nursing home with other medical services. Construction has begun on the new VA hospital, and this summer the city agreed to purchase Methodist Hospital in eastern New Orleans for $16.25 million. Mayor Mitch Landrieu's administration wants an emergency room open there in the next year. And in St. Bernard Parish, site preparation has begun to replace Chalmette Medical Center.

  The metro area had too many hospital beds before Katrina, according to Dr. Karen DeSalvo, vice dean for Community Affairs and Health Policy at Tulane's School of Medicine and co-chair of Landrieu's transition team on health care. Now the focus on hospitals needs to be on balancing distribution of beds and services, she says.

  "New Orleans East is a great example of where we don't have any hospitals for a huge land mass that is getting rapidly repopulated," DeSalvo says. "We have only one hospital in New Orleans that is delivering babies, and that's Touro."

  Hospitals and clinics play only a part in improving New Orleans' health, says Joe Kimbrell, chief executive officer of the Louisiana Public Health Institute. "You're not going to create a healthy population simply by more medical care," he says.

  "So how do you have a neighborhood that's peaceful and welcoming and livable, sort of the idea of livable communities, healthy communities, walkable, bikeable?" Kimbrell asks. "Where do you locate your schools, where do you locate your health facilities, your grocery stores, any kind of renewal in terms of housing, and how is that done?"

To be sure, many challenges remain. Doctors and patients alike see neighborhood clinics as a success, but for uninsured patients at the clinics, there remains a gap between primary and specialty care, Kimbrell says. "It's available in a very limited supply only after appointments that might be anywhere from a few months to six or eight months or a year," he says.

  Funding is also an issue. Some 43 percent of patients seen at the community clinics have no private or public health insurance, so the various providers have relied heavily on a $100 million federal grant administered through Kimbrell's organization. That money is about to run out. The state is seeking a waiver to use federal money typically reserved for hospital-based care on the clinics. The three-year waiver would bridge a gap until Medicaid expansion takes place in 2014, although it would require a local match and there would be limitations. Certain services, including dental and optometry, would not be covered.

  Hollier suggests it might be harder for the clinics to survive if they have to rely on per-patient reimbursements instead of grant money.

  Looking ahead, Hollier says he expects a shortage of doctors nationwide to continue to present challenges, and the system to be strained further as health care reform expands the number of people on Medicaid. He envisions relying more on people like nurse practitioners and physician assistants to keep up. The state of mental health care remains a "significant issue" for the city as well, Hollier says: "We lost a large number of the psychiatrists, many of whom have not come back."

  All five outpatient behavioral health clinics operated by the Metropolitan Human Services District were destroyed or damaged in Katrina. The clinics in Orleans, St. Bernard and Plaquemines parishes have mostly been rebuilt or temporary locations are in place.

  Tulane screens patients for mental health issues at each of its clinics. The Covenant House location is staffed with an internist who is board certified in psychiatry, along with a licensed clinical social worker. The two add to the holistic medical approach taken at the clinic, where a bulletin board in the lobby publicizes free legal help, a church-based produce market and drum lessons.

  "I think the future is community health centers," Tulane's Price says. "And community health centers that provide not just medical services but other types of services the person needs to be empowered to just take care of themselves in general.

  "It's already happening. I can't imagine that we're going to go backwards."


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