[Senate Hearing 109-611]
[From the U.S. Government Printing Office]



                                                        S. Hrg. 109-611
 
           LESSONS LEARNED FROM KATRINA IN PUBLIC HEALTH CARE

=======================================================================

                                HEARING

                               BEFORE THE

      SUBCOMMITTEE ON BIOTERRORISM AND PUBLIC HEALTH PREPAREDNESS

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                                   ON

   EXAMINING LEGISLATIVE IMPROVEMENTS TO ENSURE OUR NATION IS BETTER 
                 PREPARED FOR PUBLIC HEALTH EMERGENCIES

                               __________

                    JULY 14, 2006 (New Orleans, LA)

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                   MICHAEL B. ENZI, Wyoming, Chairman

JUDD GREGG, New Hampshire            EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee                CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
RICHARD BURR, North Carolina         BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia              JAMES M. JEFFORDS (I), Vermont
MIKE DeWINE, Ohio                    JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada                  PATTY MURRAY, Washington
ORRIN G. HATCH, Utah                 JACK REED, Rhode Island
JEFF SESSIONS, Alabama               HILLARY RODHAM CLINTON, New York
PAT ROBERTS, Kansas

               Katherine Brunett McGuire, Staff Director

      J. Michael Myers, Minority Staff Director and Chief Counsel

                               __________

      Subcommittee on Bioterrorism and Public Health Preparedness

                 RICHARD BURR, North Carolina, Chairman

JUDD GREGG, New Hampshire            EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee                CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
MIKE DeWINE, Ohio                    BARBARA A. MIKULSKI, Maryland
JOHN ENSIGN, Nevada                  JEFF BINGAMAN, New Mexico
ORRIN G. HATCH, Utah                 PATTY MURRAY, Washington
PAT ROBERTS, Kansas                  JACK REED, Rhode Island
MICHAEL B. ENZI, Wyoming (ex 
officio)

                     Robert Kadlec, Staff Director

                David C. Bowen, Minority Staff Director

                                  (ii)

  
?


                            C O N T E N T S

                               __________

                               STATEMENTS

                         FRIDAY, JULY 14, 2006

                                                                   Page
Burr, Hon. Richard, Chairman, Subcommittee on Bioterrorism and 
  Public Health Preparedness, opening statement..................     1
Landrieu, Hon. Mary L., a U.S. Senator from the State of 
  Louisiana, opening statement...................................    42
Alexander, Hon. Lamar, a U.S. Senator from the State of 
  Tennessee, opening statement...................................    42
Cerise, Fred, Secretary, Louisiana Department of Health and 
  Hospitals; Dr. Sharon Howard, Division of Public Health, 
  Louisiana Department of Health and Hospitals; Donald R. 
  Smithburg, CEO, Louisiana State University Healthcare Services 
  Division; Dr. Janice Letourneau, Assistant Dean, Louisiana 
  State University Health Science Center; Dr. Paul K. Whelton, 
  Senior Vice President for Health Sciences and Dean, Tulane 
  University School of Medicine; Dr. Patrick J. Quinlan, CEO, 
  Ochsner Health System; Dr. Jeffery Rouse, Deputy, New Orleans 
  Coroner's Office; and Gery Barry, CEO, Blue Cross and Blue 
  Shield of Louisiana and Vice Chair, Louisiana Healthcare 
  Redesign Collaboration.........................................     3
    Prepared statements of:
        Donald R. Smithburg......................................     9
        Janice Letourneau........................................    14
        Paul K. Whelton..........................................    19
        Patrick J. Quinlan.......................................    28
        Gery Barry...............................................    38

                                 (iii)




           LESSONS LEARNED FROM KATRINA IN PUBLIC HEALTH CARE

                              ----------                              


                         FRIDAY, JULY 14, 2006

                                       U.S. Senate,
            Subcommittee on Bioterrorism and Public Health 
             Preparedness, Committee on Health, Education, 
                                       Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 1:39 p.m. in 
the U.S. Supreme Court Hearing Room, Louisiana U.S. Supreme 
Court Building, 400 Royal Street, New Orleans, Louisiana, Hon. 
Richard Burr, chairman of the subcommittee, presiding.
    Present: Senators Burr, Alexander, and Landrieu.

                   Opening Statement of Senator Burr

    Senator Burr. Good afternoon. Let me take the opportunity 
to apologize to the panelists that we have for our tardiness. 
We'll apologize profusely to the next group, that we will loop 
back around.
    I want to thank Senator Alexander for his work at setting 
up this two-subcommittee field hearing together in New Orleans. 
We're grateful to the State of Louisiana and to the city of New 
Orleans, to Senator Landrieu, for the opportunity to learn from 
the witnesses on these two issues of critical importance, 
education and public health preparedness, which will be the 
subject of the afternoon hearing.
    I want to thank all of you for your willingness to attend 
the Subcommittee on Bioterrorism and Public Preparedness 
hearing. I'd like to take this opportunity to welcome the 
panelists and to thank them for taking the time to share your 
experiences and lessons learned from Hurricane Katrina. I know 
you are all extremely busy and I along with the entire 
subcommittee appreciate your willingness to be with you today 
and, more importantly, you with us.
    It's been almost a year since Katrina touched the shores of 
Louisiana and devastated so much of this beautiful city and the 
Gulf Coast. Its impact on the public health and the health care 
system has been significant. Then your State experienced 
Hurricane Rita. I might add here as the Senator from North 
Carolina, we're used to the annual summer experience of storms 
as well.
    Rita additionally damaged the health care system in places 
like Cameron Parish, which forced several hospitals to 
evacuate. Today your testimony will help us make the necessary 
legislative improvements to ensure our Nation is better 
prepared for public health emergencies, whether natural, 
deliberate, or accidental. This field hearing will assist us as 
we move forward to reauthorize the Public Health, Security, and 
Bioterrorism Preparedness and Response Act. That legislation, 
which was passed in 2002 shortly after 9-11, began to move this 
country in the right direction. But as we have seen from the 
effects of Hurricane Katrina, it has not done enough. We must 
ensure that the failures of Katrina are not repeated. We can 
and must do better.
    One of the pressing issues that our public health and 
medical response system faces is our ability to increase our 
capacity to take care of people in large public health 
emergencies. We need to think systematically about how to 
develop surge capacity within our health care delivery system. 
We must also maintain a well-trained and well-prepared public 
health workforce. This is no small task since 45 percent of the 
current health workforce is eligible for retirement in the next 
5 years.
    In relatively short order, I hope we will produce and mark 
up legislation that addresses a number of lessons learned from 
this disaster. I think your testimony today will provide 
critical input into that effort. I certainly look forward to 
your testimony.
    I want to once again thank Senator Landrieu for the 
incredible help that she has been, but more importantly the 
incredibly loud voice she has been for this community and for 
this State, and specifically for the health care delivery 
system. It is impossible for us in Washington, DC., to 
understand the magnitude of the disaster, and to also 
understand the tremendous magnitude of the challenge to start 
over again. We certainly are appreciative for her insight. She 
has been a tremendous spokesperson.
    We have foregone any other statements from the members and 
because we've truncated the time a little bit let me give you 
the rules. I will introduce our entire group and then we'll 
start from left and move right, if that's okay, from my left 
and move to the right. Each of you have 8 to 10 minutes to 
share with us those things that you think are most important. I 
hope that fits within the confines of what you had planned.
    Our panel today is made up of a number of individuals, and 
I'll try to get it in the correct order: Fred Cerise, 
Secretary, Louisiana Department of Health and Hospitals; Sharon 
Howard, Louisiana Department of Health and Hospitals, Division 
of Public Health; Don Smithburg, CEO, Louisiana State 
University Health Systems, which is I believe 9 of the 11 
public facilities; Dr. Letourneau, Assistant Dean, LSU; Dr. 
Whelton, Dean, Tulane University School of Medicine; Dr. 
Quinlan, Ochsner Health Systems, a four-hospital system; Dr. 
Rouse, Deputy, New Orleans Coroner's Office; and Gery Barry, 
CEO, Blue Cross and Blue Shield, and also serves as the Vice 
Chairman of the Louisiana Healthcare Redesign Collaboration.
    With that, Dr. Cerise.

STATEMENTS OF DR. FRED CERISE, SECRETARY, LOUISIANA DEPARTMENT 
OF HEALTH AND HOSPITALS; DR. SHARON HOWARD, DIVISION OF PUBLIC 
   HEALTH, LOUISIANA DEPARTMENT OF HEALTH AND HOSPITALS; DON 
SMITHBURG, CEO, LOUISIANA STATE UNIVERSITY HEALTHCARE SERVICES 
  DIVISION; DR. JANICE LETOURNEAU, ASSISTANT DEAN, LOUISIANA 
   STATE UNIVERSITY HEALTH SCIENCE CENTER; DR. PAUL WHELTON, 
  SENIOR VICE PRESIDENT FOR HEALTH SCIENCES AND DEAN, TULANE 
   UNIVERSITY SCHOOL OF MEDICINE; DR. PATRICK QUINLAN, CEO, 
 OCHSNER HEALTH SYSTEM; DR. JEFFERY ROUSE, DEPUTY, NEW ORLEANS 
  CORONER'S OFFICE; AND GERY BARRY, CEO, BLUE CROSS AND BLUE 
   SHIELD OF LOUISIANA AND VICE CHAIR, LOUISIANA HEALTHCARE 
                     REDESIGN COLLABORATION

    Dr. Cerise. Thank you, Senator, and thank all of you for 
your interest and your visit today and your support over the 
past year as we try to pick up the pieces and move forward.
    In terms of looking at public health preparedness and 
lessons that we've learned, I think the overriding lesson that 
we've seen is a basic shift in our thinking of what we make of 
a traditional public health disaster, in terms of infectious 
disease and outbreaks of disease and that type of thing, in 
regards to what we saw after this disaster, and that is just a 
total disruption of the health care delivery system and along 
with that lack of access to care for people with chronic 
disease, people with urgent needs.
    There was a lot of talk about and concern about outbreaks 
and toxic soup that people were in, and it turns out that we 
didn't have toxic soup and we didn't have outbreaks of 
diseases. We were doing surveillance on all of our shelters and 
hospitals. That didn't materialize, but probably the access to 
primary care providers, access to specialty providers, access 
to pharmaceuticals, routine things like that that were 
available before the storm, were challenged for some in the 
population, the uninsured and Medicaid population, but became a 
problem for everyone and remains a problem for some months 
later after this episode.
    So I'm going to go through a few components that stand out 
for me that would help us in the immediate phase and in the 
recovery phase as we look back and see the lessons learned. I 
can tell you, the whole experience exaggerated the deficiencies 
that we have in the system today. They just stood out. But it 
also accelerated some of the improvements that we were 
embarking upon beforehand and it's brought together people to 
move some of those improvements ahead. I'm going to give you a 
few examples.
    First, in terms of an emergency response network, we do not 
have a coordinated statewide emergency response network in 
Louisiana. That was something that we could have used at the 
time. We did okay in terms of phone calls and contacts with 
providers, but it was all pieced together in the midst of the 
hurricane, and that's how we moved people around the State. We 
know that having an emergency response network with electronic 
real-time information from providers across the State on what 
is your capacity, what can you accommodate, are important 
things. It is an important system to have in place, not only at 
the time of a crisis like this, to handle surge capacity as you 
discuss, but also it's the kind of system that can be useful 
and save lives every day when you're looking at time-sensitive 
illnesses, to be able to direct emergency personnel or someone 
with trauma or heart attack or stroke to the right place that's 
got the right capacity to treat that person with the right 
resources.
    So, coming out of this, our legislature did appropriate 
$3.5 million for some of the manpower and basic infrastructure 
to develop what's called the LERN system, Louisiana Emergency 
Response Network. It is not all we need in terms of 
connectivity to connect first responders to the ultimate 
hospital that people will be brought to, but, as I said, this 
kind of highlighted the need for that and it has jump-started 
some of the response there.
    Another area where the deficiencies were highlighted had to 
do with information technology. You're probably well aware of 
this, the many number of people who were dispersed and did not 
have adequate information on the health care, the health care 
needs of those individuals as they were dispersed, and paper 
records had either been destroyed or they were just 
inaccessible at the time.
    There were a couple of striking examples of where things 
worked well. The VA system, as you know, has a very nice 
electronic record. As veterans were displaced across the 
country, they were able to access those records and be well 
taken care of.
    There was another private-public effort that happened in 
the immediate 7 to 10 days after the hurricane called 
katrinahealth.org, where, using information from the major 
chain drugstores, from the major health plans, from Medicaid, 
using claims data, the pharmacy information was put together 
and as a physician I could call, I could call the AMA and they 
would verify that I am who I say I am, give me a password, and 
I could go to this Web site and type in a person's name, a date 
of birth, and a zip code, and if I'm from an impacted area, and 
it would give me the last 6 months of that person's 
prescription drug history, which actually pieces together a 
fair amount of the medical history from that.
    That was put together within 7 to 10 days after this 
incredible tragedy and was not--demonstrates a couple of 
things. One, you can do this type of thing. You can put these 
things together. The limitations oftentimes are human 
limitations more than the technical ability to put these 
records together.
    In the aftermath of Katrina we were able to work with the 
office of the National Center for Health Information 
Technology. Our State received a grant to help work with the 
Gulf States Collaborative to develop a prototype for a health 
information exchange to be able to share information that's 
electronically available now across providers, among providers, 
so that we will be able to access patient information in 
different sites, not just at the source where the original 
paper record resides.
    We obviously have a long way to go here. The interoperable 
piece has been jump-started and pushed ahead briskly because of 
the communications now that have occurred as a result of people 
working together in the aftermath of the hurricane, but that 
is--I think it was the highlight of the deficiency of our 
health care system, not only in Louisiana, but it's a 
deficiency nationwide, and that pushed to develop 
interoperability among various medical records not only in the 
case of a tragedy, but in the case of routine everyday office 
practice, to have information available for the patient 
wherever that person happens to show up. It improves safety, it 
improves efficiency and those types of things.
    Another area that we were challenged in, again having to do 
with people with chronic disease, was access to 
pharmaceuticals. Again, traditionally in public health 
disasters we think about things like having access to 
biologicals and things, antidotes for biological weapons, and 
that sort of medicine stockpile that is available. The 
stockpile we needed was the stockpile of medicines for blood 
pressure and diabetes and heart disease and things like that.
    As people were displaced, obviously many people then didn't 
have medication, didn't have access to that information. So 
that's another system that was put in place in the immediate 
aftermath, to try to piece that together, and going forward it 
has continued to be a challenge for us as support systems for 
people who do not have regular access to pharmaceuticals now 
had to be recreated. So that remains a challenge for us today.
    Then finally, I'm going to end on the issue of workforce 
and sharing and I'm going to say a few words about that as 
well. But I'll just say that in the immediate aftermath of the 
hurricane there was an outpouring of volunteerism. We had 
Federal teams come into the State and there was a lot of 
support for the immediate aftermath. Sustaining that response 
has been difficult. Making the transition from those Federal 
teams to using State and local resources has been a challenge. 
The reimbursement mechanisms are not set up to be able to put 
those teams in place. The rules are to fund those teams that 
come in from out of State to do that work. To be able to have 
the flexibility to engage local providers, nurses, physicians, 
and other health workers early on in the process to make that 
transition could keep those people engaged and help limit the 
spread of those workers that ended up spreading all over the 
country and also would provide that source of care for those 
individuals in smaller practices and the larger practices as 
well in trying to get back on their feet, to deal with the 
disconnect then in the number, the lack of volume of regular, 
routine visits to support that practice.
    So that's a very brief description of how I've seen the 
public health crisis in terms of really looking at it in terms 
of disruption of the delivery system for a lot of people that 
rely on that delivery system for routine care today.
    Senator Burr. Thank you, Dr. Cerise, and if I would read 
your name tag up there versus my writing I wouldn't have 
mispronounced your name. I apologize.
    Dr. Cerise. Oh, you're not the only one that does that.
    Senator Burr. Sharon.
    Dr. Howard. I think the lesson that we learned with regard 
to the public health workforce is that our public health 
infrastructure is extremely fragile, and I say it's fragile 
because of some of the things that the Senator already talked 
about: the fact that 45 percent of the workforce in public 
health is eligible for retirement. In addition to that, we have 
a shrinking workforce. I would think in the last 5 years we've 
lost over 300 nurses.
    The other concern that we have with regard to the public 
health workforce is that because of the changing role of public 
health, because of the fact that we are prepared to protect the 
health of the public as it relates to a manmade disaster or a 
natural disaster, our skill level has to be enhanced. We in 
public health are used to doing preventive health. We're used 
to doing those things that we need to do to keep the public 
healthy. But now what we have to do is we have to enhance our 
skill set because, as Dr. Cerise said, we're charged with the 
responsibility of manning special needs shelters, and when you 
staff those special needs shelters those individuals who are in 
those special needs shelters are those individuals who are 
chronically ill or who have acute medical problems, and our 
workforce is used to dealing with babies and our workforce is 
used to doing family planning, and our workforce is used to 
doing immunizations.
    So one of the lessons that we have learned is that we're 
going to have to enhance our skill set in order to be able to 
address our changing role in public health because of the fact 
that we have a shrinking workforce in public health. We have no 
redundancy. We have a lack of redundancy in staff, and that was 
quite evident during the response to Hurricane Katrina and the 
response to Hurricane Rita. Because of that lack of redundancy, 
we had people who were on their feet for hours and hours and 
hours.
    We did what we usually do. We packed 3 days of clothes, and 
they're not the best of clothes, and you go to work. So we did 
that. We packed our 3 days of clothes and it ended up being 3 
months, 4 months, 5 months, 6 months.
    We have a responsibility after the storm. The 
responsibility that we had after the storm on the environmental 
side is that we have to make sure that the water is safe for 
people to drink and we have to make sure that people get the 
information that they need to get in order to be able to come 
back into the community after the disaster and be safe.
    We issued 135 press releases during the whole response to 
Hurricane Katrina and for Rita. Normally in the span of time we 
would issue 35 press releases. But 135 press releases delivered 
everything from having that N-95 mask on when you went back in, 
to dealing with, in the beginning of the response, what you 
need to take with you to have your medications.
    I'd just like to end with your understanding that the 
public health infrastructure is fragile. But just talking about 
some of the things that we did with that public health 
infrastructure: We opened up special needs shelters across the 
State in the unimpacted area; We took care of over 2,000 
special needs patients; We sent strike teams--we're talking 
military stuff now--we sent strike teams to general shelters 
and to special needs shelters. Those strike teams were made up 
of our staff and our volunteers and our LSU partners, etcetera, 
to do immunizations.
    We did surveillance because we have a responsibility to 
check on injuries. We have responsibility to make sure that 
when you have people in these closed confined areas, large 
numbers of people, that disease doesn't spread. So we had 
surveillance teams. We called them drop-down surveillance 
teams. And we had an electronic system that we were able to 
record that information in.
    We did 110,000 tetanus shots. We managed an enormous 
donated pharmacy of pharmaceuticals and medications that were 
given to us from just the well-meaning and wonderful people 
from across the country. We managed our strategic national 
stockpile. Again, like Dr. Cerise said, we didn't have a lot of 
the things that we needed in there because basically that 
strategic national stockpile is configured in such a way that 
it is to take care of biological kinds of things. We needed 
antibiotics, we needed IV fluids, etcetera.
    So I would hope that something could be done on a 
Congressional level to kind of change the composition of that 
so that it can be for manmade disasters as well as natural 
disasters.
    I just would like to end with saying that we could not have 
done this without the help of our Federal partners. We could 
not have done this without the help of our private hospitals 
and our public hospitals in Louisiana. We also had the 
responsibility of credentialing over 2,000 volunteers that came 
to the State to help us.
    Senator Burr. Thank you, Ms. Howard.
    Don Smithburg.
    Mr. Smithburg. Thank you, Mr. Chairman, members of the 
committee. I'm Don Smithburg, CEO of the LSU Hospitals and 
Clinics here in Louisiana. We thank you for your interest in 
health care in Louisiana, especially after Katrina and Rita. I 
particularly want to thank and recognize and acknowledge 
Senator Landrieu for her extraordinary leadership both here in 
the affected area and of course on Capitol Hill. I also thank 
you for your invitation to appear here today and the 
opportunity to at least attempt to answer any questions that 
you may have about the public hospital system and what we've 
learned from the catastrophe and about how we are preparing for 
the future.
    I represent 9 of the 11 State public hospitals and over 300 
clinics that traditionally have been called here in Louisiana 
the charity hospital system. In other States what would be 
known as a county hospital is actually under the state-owned 
governance structure through LSU here in Louisiana, and all of 
those public hospitals that you might know of as being locally 
governed is actually under the State aegis here.
    Our hospitals and clinics constitute the health care safety 
net, as a result, for the State's underinsured and uninsured, 
particularly the working uninsured. We see two-thirds of our 
patients have traditionally been hard-working, employed 
Americans. Louisiana has one of the highest rates of 
uninsurance in the Nation. Over 20 percent of the population 
have nothing and another 21 percent of our citizens in 
Louisiana are on Medicaid, and that was before Rita and 
Katrina. Since the hurricanes, there is an estimated 120,000-
U.S.-person increase in the ranks of the uninsured as 
businesses fail because of the storms' destruction.
    The LSU hospitals have also played an integral role in 
supporting the education programs of our medical schools and 
health training institutions. Our flagship hospital here in New 
Orleans is commonly known as ``Big Charity.'' It's actually two 
facilities, the charity hospital and university hospital, 
operated as one medical center umbrella. It also includes the 
only trauma center in south Louisiana. There were thousands of 
Tulane and LSU students and residents in training when Katrina 
hit here in New Orleans and when her floods forced the multiple 
failures in the levees.
    In recent months, LSU and the Department of Veterans 
Administration have been engaged in an historic and 
collaborative effort that we hope will result in rebuilding one 
chassis that will support two hurricane-hardened hospitals, 
both able to better serve their respective patient populations 
and conserve Federal and State resources at the same time.
    Now, what happened at Big Charity when the levees failed? 
In brief, the city's streets and hospital basements flooded. 
Power to the city was lost and hospital emergency generators 
were able to operate for only a short time because of a lack of 
access of fuel to feed those generators. Supplies of essentials 
such as food and water were not allowed to be brought in to 
augment our own depleted stores. Restrooms did not work and 
maintaining sanitary conditions was difficult at best. External 
communications were exceedingly limited.
    The result was that patient care and safety was 
compromised, especially for such critically ill patients as 
those on ventilators. Staff in the hospitals worked heroically 
to care for patients, manually ventilating some for hours and 
then for days. It became imperative to evacuate both patients 
and staff, but the hospital itself had no means to do so.
    The committee is perhaps looking for the lessons from this 
disaster with an eye toward improving not only the Gulf Coast 
emergency preparedness, but also that of a potentially 
vulnerable Nation. From our perspective there were several 
general lessons and many others at the hospital operational 
level. On evacuation, there proved to be in our view inadequate 
ability or insufficient priority to evacuate patients and staff 
from Big Charity in a reasonable period of time. In the future 
we will not again assume that agencies that are physically and 
bureaucratically remote from our hospitals will come to our 
rescue. Instead, we have developed a means to transport 
patients and staff should the need arise.
    In fact, when Rita approached southwest Louisiana a few 
short weeks after Katrina--and we operate facilities in 
southwest Louisiana as well--we did evacuate threatened 
patients and staff from Lake Charles, Lafayette, and Homa, 
Louisiana, to facilities in Baton Rouge and Alexandria that 
were out of harm's way. We took care of ourselves without 
asking or expecting help, and it worked.
    At this point, our 2006 evacuation costs are unbudgeted and 
are conservatively estimated at $2 million to $4 million this 
season just for our anticipated hospital evacuations in New 
Orleans, Homa, and Lafayette. Because our region suffered and 
continues to suffer, we likely will be evacuating from storms 
that if it weren't for Katrina we would not have considered 
leaving.
    I fear that our fear may create patient care risks, 
although I have no real solution for that dilemma.
    Another major lesson from the crisis was the need for 
reliable communications, as has already been described. Our 
police radios in New Orleans and other affected areas worked, 
but only intermittently. Ham radio was most reliable, but it's 
slow. Satellite phones were generally useless for us. The 
communications problem undoubtedly does have a technological 
problem and we need to determine the best way to stay in touch 
in emergencies and put the appropriate equipment in the right 
hands.
    In a time of major emergency, it became clear that our 
public hospitals are embedded in an extended, multilevel, 
multiagency, multigovernment bureaucratic structure, no one 
part of which is responsible for our rescue. We do not have a 
single parent organization to act on our behalf, such as the VA 
or private hospital companies, but instead are dependent on the 
coordination and the gelling of a diverse set of scattered 
entities that work together only intermittently and in some 
cases with unrelated contract employees brought on for a 
particular disaster, such as the FEMA structure.
    Let me emphasize this. After Katrina's floods struck, the 
State Department of Health and Hospitals, the Louisiana 
Hospital Association, and others of authority quickly 
determined that our public hospital should be in the top 
priority group for evacuation, given the critical condition of 
our patients. They were and have been consistent on that. We 
were all rowing in the same direction, and then suddenly some 
other authority seemed to supersede.
    To this day, I do not know if the evacuation priorities 
were reordered once teams got to New Orleans or when FEMA got 
involved or if anyone actually coordinated our hospital rescue. 
I do know that numerous State agencies and military branches 
were logistically involved, performed well, as did private 
resources, but under whose order, if any, remains a mystery.
    We learned many other lessons and have developed ongoing 
plans and processes to take the actions that these lessons have 
taught us. Some of these identified needs are: host facilities 
able to accommodate evacuated patients. This includes 
developing surge capacity on our own hospitals--and I'm almost 
done--and making other arrangements, such as temporary housing.
    We have within our system the capability to accommodate 
surge capacity, but in Katrina our plan was overridden. We lost 
contact with all of our patients and thousands of our staff.
    A system to provide a continuing flow of information on 
evacuated patients and staff. This involves creating backup IT 
systems and protection of medical records from potential 
damage.
    This is very key to us: Temporary housing for staff whose 
homes were destroyed or damaged, but who are able to work in 
the disaster area.
    Last, security to protect our people and our assets.
    We know now that it is essential to plan for the worst 
case, not just something approaching it, and to prepare for the 
aftermath of a crisis, not just the episode itself. As was 
quoted in the New York Times just a couple of weeks ago by a 
New Orleanian as she was commenting about depression and 
suicide, quote: ``I thought I could weather the storm and I 
did. It's the aftermath that's killing me.''
    Thank you very much.
    [The prepared statement of Mr. Smithburg follows:]
               Prepared Statement of Donald R. Smithburg
    Mr. Chairman and members of the committee, I'm Don Smithburg, CEO 
of the LSU Hospital & Clinic System in Louisiana. I thank you for your 
interest in health care and in Louisiana after Katrina and Rita. I also 
thank you for your invitation to appear today and the opportunity to 
answer any questions you may have about Louisiana's State public 
hospital system, about what we have learned from catastrophe, and about 
how we are preparing for the future.
    I represent 9 of the 11 State public hospitals and over 350 clinics 
that traditionally have been called the ``charity hospital system'' in 
Louisiana. I would like to describe this system briefly.
    Our hospitals and their clinics constitute the health care safety 
net for the State's uninsured and underinsured, particularly the 
working uninsured--\2/3\ of our patients are hard-working Americans. In 
your States, this role is generally a local government function, but in 
Louisiana it is the responsibility of a state-run and statewide 
hospital and clinic system under the aegis of LSU. Every individual in 
the State is eligible to receive services in any of our facilities 
regardless of where they live or their ability to pay. Louisiana has 
one of the highest rates of uninsurance in the Nation; over 20 percent 
of the population and estimated to include over 900,000 individuals. 
Another 21 percent of the citizenry is on Medicaid. So 41 percent of 
Louisiana's population is without private health insurance. That was 
before Katrina and Rita. Blue Cross of Louisiana has recently projected 
a 120,000 person increase in the ranks of the uninsured as businesses 
fail because of the storms' destruction. In New Orleans alone, the 
uninsurance rate is 41 percent since Katrina.
    The LSU hospitals also have played an integral role in supporting 
the education programs of our medical schools and training 
institutions, and that includes not only LSU but also Tulane and the 
Ochsner Clinic Foundation. Our LSU system flagship is in New Orleans, 
commonly known as ``Big Charity,'' is actually two facilities, Charity 
Hospital and University Hospital, operated under one medical center 
umbrella. At our New Orleans facility alone, there were over 1,000 
Tulane and LSU medical students and residents in training, and many 
more nursing & allied health students, when Katrina struck and the 
multiple levee failures devastated our institution.
    Some of these same students at Big Charity had rotations at the VA 
hospital in New Orleans as well. The VA facility sits a stone's throw 
from Big Charity and was also devastated by the flooding. In recent 
months, LSU and the Department of Veterans Affairs have been engaged in 
an historic and collaborative effort that we hope will result in 
rebuilding one plant that will support two hurricane-hardened 
hospitals, both are able to better serve their respective patient 
populations and conserve Federal and State resources at the same time.
    I know you will understand that the destruction of Charity Hospital 
is felt especially deeply here. ``Big Charity'' was the second oldest 
continuing hospital in the Nation and has endured as one of the most 
significant medical institutions in the Nation over the 270 years. It 
was established in 1736. The hospital was destroyed once before by a 
hurricane, in 1779, but rebuilt just 5 years later; without FEMA, by 
the way. Today, it sits in ruins.
                         emergency preparedness
    Having created both a statewide and a public hospital system, it is 
natural and appropriate that Louisiana would turn to this system in 
times of emergency. Under State emergency preparedness plans, our 
hospitals are designated as the lead facilities in each region to 
accept patients who have special acute needs that may become emergent 
in a crisis or catastrophe. We have regarded it as our hospitals' 
obligation to gear up for potential disasters and to continue to 
operate when others may not be able to. We have the capacity as a 
system to transfer patients to our facilities in other parts of the 
State, if necessary. And since Louisiana's only Level I trauma and 
specialty care centers--in New Orleans and Shreveport--are operated by 
LSU, special medical needs generally could be accommodated internally.
    Louisiana's emergency preparedness plans, and our role in them, 
were fundamentally sound up to a point. Clearly, that point was 
surpassed by the magnitude of Katrina in the New Orleans area. Our 
hospitals were prepared to help the victims of disaster, but not to be 
a victim ourselves.
          the reality of disaster and the paucity of response
    What happened at Charity and University Hospitals when the levees 
failed? In brief, the city streets and hospital basements flooded. 
Power in the city was lost and hospital emergency generators were able 
to operate for only a short time because of lack of fuel. Supplies of 
essentials, such as food and water, were not allowed to be brought in 
despite our attempt to deliver such basic supplies and provisions. 
Restrooms did not work and maintaining sanitary conditions was 
difficult. External communications were exceedingly limited since 
telephones generally did not work. The sentinel result was that patient 
care and safety was compromised, especially for such critically ill 
patients as those on ventilators. Conditions didn't meet the standards 
we would expect of Third World countries. Staff in the hospitals worked 
heroically to care for patients, manually ventilating some for hours 
and then days. In a few instances staff administered intravenous 
nutrition to one another. In sum, it became imperative to evacuate both 
patients and staff. But the hospital itself had no means to do so.
    You are looking for the lessons from this disaster with an eye 
toward improving not only Louisiana's future emergency preparedness, 
but also that of a vulnerable Nation. From our perspective, there were 
several general lessons and many others at the hospital operational 
level.
    Evacuation. First, as this committee is aware, there proved to be 
inadequate ability--or insufficient priority--to evacuate patients and 
staff at Charity and University Hospitals within a reasonable period of 
time. In the future we will not again assume that agencies that are 
physically and bureaucratically remote from our hospitals will come to 
our rescue. Instead, we have developed the means to transport patients 
and staff should the need arise. Quite simply, a trauma center is 
designed to stand in place in order to take in casualties after a 
disaster. This season, we are prepared to evacuate without reliance on 
the government.
    Should assistance be available, we will gladly accept it, and 
certainly we will work cooperatively with agencies at any level to 
create an effective means to deal with all aspects of emergencies such 
as Katrina and Rita. But we will also exercise our capacity to take 
care of our own people within our system.
    In fact, when Rita threatened Southwest Louisiana a few short weeks 
after Katrina, we did evacuate threatened patients and staff from Lake 
Charles, Lafayette and Houma to facilities in Baton Rouge and 
Alexandria. We didn't wait for the established cavalry as we did after 
Katrina's floods. We became our own cavalry and took care of ourselves 
without asking or expecting help. And it worked.
    Since the storms, we have developed contracts with out-of-state 
ambulance companies to be available to transport patients in the event 
of emergency. These contracts stipulate that the companies' capacity 
must be devoted exclusively to our hospitals for the particular 
emergency. We hope that FEMA would reimburse our system should a future 
catastrophe require the activation of these transportation services. At 
this point, our 2006 evacuation costs are unbudgeted, but are estimated 
at $2.5 million this season for evacuations affecting New Orleans, 
Houma and Lafayette.
    Communications. One major lesson from this crisis was the need for 
reliable communications. Both in New Orleans and Bogalusa (along the 
Louisiana-Mississippi border, where our hospital received serious wind 
damage, communications with our central office, the State Office of 
Emergency Preparedness and others were exceedingly difficult. In the 
case of Bogalusa, there was silence for 2 days. Our police radios 
worked in New Orleans, but only intermittently in about 45 second 
intervals. Ham radio was most reliable, and it is a technology we will 
continue to invest in--but it is slow. Interestingly, cell phone text-
messaging worked in a number of cases even though cell phone 
conversations often did not. Satellite phones were generally useless 
for us. Although several different technologies failed or were of very 
limited use, the communications problem undoubtedly has a technological 
solution. We need to determine the best way to stay in touch in 
emergencies, and put the appropriate equipment into the right hands.
    It is not enough to have disaster plans. We must understand what 
they call for and be prepared to implement them unless unforeseen and 
overriding factors arise. To give you one concrete example, despite the 
designated role of our hospitals to receive evacuated patients, we 
received far fewer than we had capacity for. I personally worked at the 
State Office of Emergency Preparedness headquarters to help move both 
the patients and the staff from Charity and University to other LSU 
hospitals that were prepared to accept them, but this approach--the 
planned approach--was overruled by FEMA. Instead, patients from Charity 
and University Hospital were taken to the N.O. airport, ultimately put 
on military transports and scattered across the country. Only medical 
records, but no staff, accompanied them. To our knowledge, no record 
was kept of who was on what plane, where they came from or where they 
were taken.
    Immediately after the evacuation, it was as if our patients had 
disappeared, and when the calls from families came asking about those 
in our care, we could not tell them where they were. Staff spent 
literally weeks calling hospitals across the country asking if any of 
our patients had been transferred there. Despite these efforts and 
those of the Louisiana Hospital Association, we never did find out 
where all our patients were taken.
    In a time of major emergency, it became clear that our hospital is 
imbedded in an extended, multilevel, multiagency, multigovernment 
bureaucratic structure, no one part of which was responsible for our 
rescue. We do not have a single ``parent'' organization to act on our 
behalf, such as the VA or hospital companies, but instead are dependent 
upon the coordination and the jelling of an exceedingly diverse set of 
scattered entities that work together only intermittently and in some 
cases with contract employees brought on for a particular disaster.
    Hopefully, something can be done to tighten this structure. But its 
deficiencies are the reason that we must establish contingency plans to 
take care of ourselves.
    Other Lessons. We learned many other lessons and have developed 
ongoing plans and processes to take the actions that these lessons 
taught. Identified needs include:

     A stockpile of supplies for a longer period than 
previously thought, at least 2 weeks. Supplies should include food, 
water, medications, generators, gasoline, flashlights, and red bags and 
buckets with lids.
     Receiving facilities able to accommodate evacuated 
patients. Includes developing surge capacity in our own hospitals and 
making other arrangements such as temporary housing as well.
     A system to provide a continuing flow of information on 
evacuated patients and staff, including clinical information, location, 
and family contacts. This involves creating backup capacity for 
clinical IS systems and protection of medical records from potential 
damage.
     Temporary housing for staff whose homes were destroyed or 
damaged but who were able to work.
     Security to protect our people and our assets.

    We have also come to understand that we must help shape the 
capabilities and expectations of the outside world. We cannot afford 
for emergency preparedness entities and health care providers to 
maintain unrealistic expectations of what our hospitals can do in the 
event of a disaster that overwhelms us all. Coping with disaster is our 
problem, and we hope it is on the way toward resolution. All providers 
and agencies must craft realistic contingency plans of their own.
    We know now that it is essential to plan for the worst case, not 
just something approaching it, and to prepare for the aftermath of a 
crisis not just the immediate crisis period itself. As was quoted in 
the New York Times 2 weeks ago, a New Orleanian said as she reflected 
on depression and suicide: ``I thought I could weather the storm, and I 
did. It's the aftermath that is killing me.''
    Thank you again for your interest and for the opportunity to share 
LSU's perspectives on these critical matters.

    Senator Burr. Thank you, Mr. Smithburg.
    Dr. Letourneau.
    Dr. Letourneau. Thank you, Mr. Chairman, and subcommittee 
members and staff.
    There are many lessons from Katrina--patient, cultural, 
operational, and personal lessons. Today I will relate some of 
the lessons we have learned in the context of our sizable 
research enterprise. As a matter of introduction, since I'm not 
Dr. Hollier, I am Janice Letourneau. I'm Associate Dean for 
Faculty and Institutional Affairs at the LSU School of Medicine 
here in New Orleans, Professor of Radiology and Surgery, an 
academic physician.
    As the representative from the academic component of LSU, 
I'm pleased and wish to thank the members of the subcommittee, 
as well as those from multiple Federal agencies and our 
Congressional contingency, for all their support and 
intervention during the storm and in the aftermath. It really 
was an incredible disaster and, as Don has mentioned, it 
remains a disaster.
    LSU Health Sciences Center in New Orleans is comprised of 
six professional schools and it serves the health care needs of 
1 million patients each year. Katrina and its attendant 
flooding severely impacted the center, forcing us to 
temporarily relocate to Baton Rouge. Both the academic campus 
and the two major teaching hospitals were flooded. As a 
consequence, we continue to recover in a very strategic and 
global way.
    Over the past 10 years, the State has invested heavily in 
us as an institution, its infrastructure, and also its research 
programs. As a result, we were in a growing phase. We had added 
100 new faculties over the 3 years preceding Katrina. With 
that, we saw a dramatic increase in our research programs. A 
good example is the addition of four new basic science 
department heads in the school of medicine over the last 4 
years. These people did what they were supposed to do: They 
hired new faculty--talented people that came in with funding, 
developed new sources of funding; and our successes are 
outlined in the table that's included in the printed testimony.
    Coincident with the growth in the faculty, we saw expansion 
of our graduate and our post-doctoral training programs and 
continued growth of our interdisciplinary research institutes 
and centers.
    But the storm changed all of that. It challenged our 
ability to maintain our existing programs and it really 
arrested our ability to operate in any way that we knew from 
the past. Progress was basically arrested by the physical 
damage and the human tragedy of Katrina. For example, with this 
disruption of clinical services that you've heard about 
execution of clinical trials has become very difficult and as a 
consequence of that the Health Sciences Center and the school 
have lost $7 million in annual revenue in comparison with last 
year, just on the basis of clinical trials. Additionally, 17 
NIH-funded investigators have left the institution since the 
storm, leaving with them about $5.5 million of funding.
    Immediately following the evacuation we established 
ourselves operationally in Baton Rouge. The infrastructure for 
operations was quickly established and really miraculously we 
started classes within 4 weeks to the day from landfall of 
Katrina. Temporary administrative, teaching, and some research 
space was established at Pennington. But the two hugest 
challenges that we faced were really communication and housing. 
The communications strategies are outlined in the printed 
testimony. Housing was addressed more creatively in conjunction 
with an important commitment by FEMA to provide funding for a 
Finnjet passenger ferry and also for temporary trailer housing 
on the LSU campus.
    After restarting our classes, we looked--we turned next to 
the continuity of our research programs, assuming that our 
campus would really not be habitable for the next 6 to 9 
months. Individual investigators developed idiosyncratic 
strategies along with their supervisors, identifying their 
family needs, their laboratory needs. Some of these people 
wound up staying in the Baton Rouge area. Some of them went in 
dispersed fashion around the country to host institutions and 
with other scientists as they re-established their research 
program. There really was a diaspora of our investigators 
around the country and to some extent around the world.
    As the city became more inhabited, temporary facilities 
were also established at our partner institution, the Research 
Institute for Children at Children's Hospital, and also at 
Ochsner.
    This has also been a pretty productive time for our faculty 
for grant-writing because the labs haven't been fully 
operational, and the successes that we've had in grant-writing 
are also outlined in the testimony.
    The campus was flooded with 3 to 7 feet of water and that 
destroyed the electrical and mechanical systems of our major 
buildings. Five major multistory buildings were affected on the 
downtown campus, as were two major buildings on the dentistry 
campus. The estimated losses range at this point, with 
assessments still ongoing, at about $100 million.
    The content loss, particularly the losses of research 
animals and biomedical specimens, are particularly difficult to 
value.
    Things are looking up. We've been back on campus now for 6 
months doing research. Our buildings are mostly open. The 
ground floors remain closed. Now, at 9 and 10 months, classes 
are resuming. Administrative operations have also resumed here 
in downtown New Orleans. The School of Dentistry will likely 
remain in Baton Rouge for the entire coming year.
    What are the lessons? Our immediate goal is to focus on 
faculty retention and continuity of our research program, but 
the lessons are: that a clear understanding and commitment to 
the institution's mission--education, discovery, and service--
is critical to maintaining the loyalty and morale of students, 
staff, and faculty. In a disaster of this magnitude, crisis 
management, assessment, recovery, and even rebuilding all occur 
contemporaneously. Information is very dynamic in nature and 
communication becomes even more important than it was before, 
and communication pathways must be redundant.
    Assessment of facility and scientific loss is extremely 
complicated and difficult, and our senior investigators have 
helped tremendously with excellent recommendations on 
mitigating damages and minimizing losses for the future. 
Retention of students and faculty is critical to restoration of 
successful scientific programs. The departure of scientists 
after Katrina is most frequently associated, not just with 
professional losses, but with the personal losses and 
frustrations that they've experienced as well. Some of the loss 
of funding has been counterbalanced by new opportunities and 
funding that's arisen.
    Several factors have contributed to the survival of our 
research enterprise, including the investments that we've 
talked about before by the State and Federal Government, the 
resilience and creativity of our leaders, the thoughtful 
support and intervention of multiple agencies, as we've talked 
before. But the research enterprise is still very fragile, but 
there is an exciting set of opportunities on the horizon.
    There is a new announcement today from the NIH, thanks to 
Dr. Zerhouni and Hitt, providing for a funded 1-year extension 
on 
R-type research grants for investigators who choose to stay in 
New Orleans. With these kinds of opportunities, we hope that we 
will emerge with a new focus and energy in the pursuit of our 
scientific discovery.
    Thank you very much.
    [The prepared statement of Dr. Letourneau follows:]
                Prepared Statement of Janice Letourneau
                           overview of growth
    The Louisiana State University Health Sciences Center in New 
Orleans (LSUHSC-NO) is the primary care provider for all citizens in 
the State of Louisiana. It serves 1,000,000 patients a year and is the 
primary educational center for health care professionals in the State, 
and comprises Schools of Medicine, Graduate Studies, Dentistry, 
Nursing, Allied Health, and Public Health. Hurricane Katrina, which 
struck southeastern Louisiana on Monday, August 29, 2005, has severely 
impacted the education, service, and research mission of the Health 
Sciences Center, essentially requiring a temporary relocation of the 
Center to Baton Rouge, which is 60 miles inland from New Orleans. The 
two major teaching hospitals for LSUHSC in New Orleans (Charity and 
University Hospitals) were flooded and Charity suffered significant 
structural damage. There is a tremendous ongoing institutional planning 
effort for continued recovery of this academic medical center.
    The past 10 years have witnessed a tremendous State investment in 
LSUHSC-NO, which has resulted in dramatic growth in its research 
programs. This investment included infrastructure development, research 
resources and the successful recruitment of new department heads, a new 
Dean of the School of Medicine, a new Chancellor of the Health Sciences 
Center and the creation of a School of Public Health. This has resulted 
in a true sense of mission at the Health Sciences Center, and in the 
recruitment of 100 new faculty members over the past 3 years. All of 
this progress has essentially been brought to a halt by the damage and 
human tragedy inflicted by Hurricane Katrina.
    Within the Basic Science Departments at LSUHSC-NO, four new Heads 
of Departments (Genetics in 2000, Pharmacology in 2001, Physiology in 
2002, Biochemistry in 2004) were recruited within the last 4 years, and 
LSUHSC-NO is currently recruiting a new Head for the Department of 
Anatomy and Cell Biology. This has resulted in the expected additional 
recruitment of talented, NIH funded faculty and further infrastructure 
development in terms of space, equipment, and core research support 
services. Coincident with this growth has been the significant 
expansion of graduate and post-doctoral research training programs and 
the continued growth of Centers of Excellence in Alcohol Research, 
Cancer, Cardiovascular Biology, Research Institute for Children, Oral 
Biology and Neuroscience and expansion of programs in Gene Therapy, 
Human Genetics, Immunobiology and Infectious Diseases.
    Because of this activity, NIH supported research on campus has 
increased from $18,743,273 in fiscal year 2001 to $39,950,000 for 
fiscal year 2006 (through 3-1-06). The storm, however, has had a 
serious impact on our progress. For example, clinical trials were 
deeply impacted by Katrina with a loss of more than $7,000,000 from 
fiscal year 2005 to fiscal year 2006. Seventeen NIH funded 
investigators have left the institution since the hurricane for a total 
loss of $5.7M per year. Table 1 provides historical data regarding 
LSUHSC-NO research awards.

                 Table 1.--LSU Health Sciences Center in New Orleans Historical Research Awards
----------------------------------------------------------------------------------------------------------------
                                       FY-2001       FY-2002        FY-2003     FY-2004     FY-2005     FY-2006
----------------------------------------------------------------------------------------------------------------
NIH................................  18,105,247       19,503,425  21,228,872  35,738,211  37,192,393  38,950,000
NIH Subcontract....................     633,026        2,137,522   1,953,888   2,387,258   2,402,823   1,518,873
Other Federal......................   2.324,944        3,934,947   7,152,543   5,946,337   4,903,991   1,997,611
Private............................   3,266,902        5,950,971   3,257,737   4,111,303   4,947,378   2,582,949
State..............................   8,061,668        8,201,246   9,810,431   8,628,646   3,833,636   2,541,984
Clinical Trial.....................   5,948,597       11,642,094   7,805,895   7,546,581   9,013,377   1,855,564
                                    ----------------------------------------------------------------------------
  Total............................  38,340,384       51,370,205  51,209,365  64,358,336  62,293,598  49,446,981
Included Above:
  NIH Supplements (15 request).....                   10 Awarded               1,192,000
  NIH Awards Since Katrina.........                12 New Awards               4,384,188
----------------------------------------------------------------------------------------------------------------


    The recruitment of Larry Hollier, M.D. from Mt. Sinai Medical 
Center as Dean of the School of Medicine in January of 2004 and his 
recent appointment as Chancellor of the Health Sciences Center has 
provided further impetus for growth and expansion. Thus, LSUHSC-NO has 
a group of experienced and respected leaders committed to the 
development of educational and research programs at the forefront of 
academic medical centers.
                    post-katrina recovery activities
    Following the evacuation from New Orleans, administration and 
support services for the Health Sciences Center were established in 
Baton Rouge. An organizational center was established at the LSU 
systems office in Baton Rouge during the storm and this served as base 
camp for leadership and staff. Information was provided through the 
LSUHSC Web site and by using phones to answer questions from students, 
staff, and faculty.
    The Health Sciences Center in New Orleans was temporarily relocated 
in Baton Rouge. Classes began on Monday, September 26 for all of its 
schools. Infrastructure required for operations were quickly 
established (i.e. Information Technology, Human Resources, Benefits, 
Grants Administration). All financial systems became operational within 
2 weeks of the storm and all payrolls were delivered. This was a 
tremendous undertaking.
    One of the biggest challenges in completing the operational 
initiative of the Health Sciences Center when it relocated to Baton 
Rouge was finding housing for faculty, student, and staff. Baton Rouge 
doubled its population due to the influx of New Orleans evacuees. 
LSUHSC-NO addressed this need by providing a FinnJet Ferry Boat docked 
on the Mississippi River that housed up to 1,000 students, faculty, and 
staff. In addition, 400 one and two bedroom trailers were place on LSU 
property in Baton Rouge as part of a University Village for faculty and 
students.
    At the departmental level, chairs communicated with faculty 
immediately after the storm through text message since direct phone 
calls were problematic. The LSUHSC e-mail system was down for 2 weeks 
further complicating communications. As expected, individuals evacuated 
to different areas of the country to find a personal comfort zone for 
their families. LSUHSC-NO's priority was the personal safety of its 
students, faculty, and staff.
    Through text messaging, limited phone connections, and alternative 
e-mail accounts the Health Sciences Center community was able to 
establish and maintain contact. The great majority of faculty and staff 
suffered personal loss and damage to homes to varying degrees. Many 
faculty, staff, and students completely lost their homes.
    Our mission during this time was to provide a personal and 
professional anchor for individuals. LSUHSC-NO held conference calls 
with the faculty and also with students to bring people together for 
mutual support.
             continuity of research and education programs
    The next step was to provide a mechanism for continuity of our 
research and education programs as individuals tackled the issues 
facing them. Due to the importance of finding a personal comfort zone, 
it was decided either to support faculty in Baton Rouge with lab space 
or to work with other universities where faculty may have found that 
comfort zone for the family and their specific situation. Initial 
anticipated timeframe of 6-9 months following Hurricane Katrina for an 
operational campus at LSUHSC in New Orleans, the Health Sciences Center 
moved aggressively to make sure that investigators in temporary 
locations had what they needed in terms of space, equipment, and 
resources.
    Financial systems were made operational, and a research supply 
store was set up at Pennington Biomedical Research Center. In addition, 
each investigator was provided with a ``purchasing card'' so that they 
could buy what they needed immediately. For investigators at different 
universities, LSUHSC-NO covered all personnel and supply costs through 
LSUHSC as normal and arrangements were made for direct shipping of 
supplies and reagents to the investigator's laboratory.
    The laboratories were made operational by sharing equipment, buying 
small equipment used on a daily basis, obtaining additional items from 
individual laboratories at the Health Sciences Center, and the 
graciousness of the individual institutions housing the investigators.
    Graduate students beyond the first year of the program were with 
their mentors or collaborators as were fellows. First year students 
began classes in the interdisciplinary course framework of the School 
of Graduate Studies on Monday, September 26 in Baton Rouge and these 
classes started in New Orleans beginning January 2006.
    In many cases, individual faculty gravitated toward the labs of 
established collaborators. Several faculty set up operational space at 
LSU affiliated schools or centers in Baton Rouge (Pennington Biomedical 
Research Center, LSU School of Veterinary Medicine, LSU School of Life 
Sciences) while others set up their laboratory at other institutions 
across the country.
    In mid-November, laboratories were set up at Children's Research 
Institute at Children's Hospital and the Ochsner Clinic Foundation in 
New Orleans as many faculty members and staff began to return home to 
New Orleans.
    In addition to laboratory activities, 105 grants were submitted to 
NIH since Hurricane Katrina hit the coast. Fifty-eight of these grants 
were new submissions. As of 3/1/06, 15 requests for administrative 
supplements ($3,717,329) have been submitted to NIH post-Katrina; 10 of 
these requests have been awarded for a total of $1,192,000.
    LSUHSC-NO was contacted by multiple institutions, colleagues, and 
departments around the country offering space, support, and 
encouragement. The numerous and generous offers of lab space and 
support from the research community has provided flexibility to address 
our challenges. All of the individual programs, investigators, and 
institutions that welcomed displaced investigators should be recognized 
for their tremendous effort, graciousness, support, and hospitality.
                           damage assessment
    The entire Health Sciences Center was flooded with 3-7 feet of 
water on the first floor of each building, which destroyed electrical 
cores, water pumps, and fire pumps. Five major buildings with 5-10 
floors each were affected on the downtown campus and the two major 
buildings on the School of Dentistry campus. A full-assessment of 
damage to the buildings and the full extent of lost research material 
and damage to equipment is ongoing. A detailed report with daily 
updates can be monitored at http://www.lsuhsc.edu/.
    The personal damages along with the losses and disruptions of 
research programs are having a severe impact on career development for 
both new and established investigators. It should not be overlooked 
that this impact also includes the graduate students and post-doctoral 
fellows. This includes issues with manuscript generation and 
publication delays as well as grant submissions and grant renewals, all 
of which will have a lasting impact on our mission and the many 
contributions of the NIH and NSF supported research programs in 
Louisiana.
                       the return to new orleans
    Less than 6 months after the floodwaters left the downtown campus, 
the upper floors of the Medical Education Building, the Lion's/LSU 
Clinic Building and the Mervin L. Trail Clinical Sciences Research 
Building were opened, allowing researchers to move back into their 
labs.
    Just 9 months after Hurricane Katrina forced the institution to 
relocate all of its classes and operations, the majority of the 
downtown campus functions have returned. Classes have begun for the 
Schools of Allied Health Professions, Graduate Studies, Medicine, 
Nursing, and Public Health. The two student residence halls have 
reopened, along with the Library, Administration, and Resource Center.
    On the Florida Avenue Campus, which sustained the worst flooding, 
work on the Dental School Clinical and Administration Building is 
ongoing. The School of Dentistry has organized its efforts in Baton 
Rouge and continues to educate its dental students, dental hygiene 
students, dental laboratory technology students, and residents. In 
addition, a 32-chair clinic, a student dental laboratory, and a 
preclinical laboratory continue to be housed in three vacant buildings 
made available through Louisiana State University.
                                summary
    In summary, our immediate goal is to focus on faculty retention and 
continuity of our research programs. We will also concentrate on 
programmatic development with emphasis on program retention and 
institutional restoration.

    Senator Burr. Thank you, Dr. LeTourneau. We are also 
pleased with Dr. Zerhouni's decision and I think that shows 
just the type of leadership we've got at the NIH.
    Dr. Whelton. Senator Burr, Senator Alexander, it's an honor 
to welcome you to the city and I'm very grateful that you're 
here to see our progress and our challenges firsthand.
    In the immediate aftermath of Hurricane Katrina, I learned 
several valuable lessons. First I should say, faced with an 
overwhelming crisis, health care providers performed in an 
exceptional manner and they are among my heroes of Katrina.
    Second, the academic community, key Federal agencies, 
especially for us the NIH and CDC, the local health care 
institutions, including Ochsner, have been unbelievably 
supportive.
    Third, New Orleans was probably better prepared for an 
emergency than most cities in the United States, but certainly 
our city, even though better prepared, was not sufficiently 
prepared for an overwhelming challenge like Katrina. Before 
Katrina our medical group cared for approximately 50,000-odd 
patients per month. Immediately after the storm, they 
established clinics, many free clinics. We reopened our health 
sciences buildings in October, our Tulane Lakeside Hospital in 
November, and our downtown university hospital in February. 
We've progressively increased both clinical availability and 
the number of inpatient beds, which, while still much lower 
than pre-Katrina, now we have an average daily census of about 
200 and we expect to get back up to 300 to 400 in the 
foreseeable future.
    In order to assure a cadre of well prepared public health 
professionals in Alabama, Arkansas, Louisiana, and Mississippi, 
we've worked very hard to advance our Tulane South Central 
Center for Public Health Preparedness. This center trains more 
than 17,000 front-line practitioners and public health leaders, 
and we've added a variety of training opportunities specific to 
the lessons learned from Katrina.
    Talking a little bit about our research enterprise, despite 
Katrina-related losses of more than $120 million in research 
income and facilities, we're back on our feet and I expect that 
our research awards during the current year will be somewhere 
between $100 million and $105 million. That is about 95 percent 
of our awards last year.
    I want to turn for a moment to talk a little bit about my 
view of the current State of health care in New Orleans. Let me 
first talk about patients. If your schedule had permitted an 
opportunity to tour our facilities, you would have seen very 
busy clinics, overcrowded emergency rooms, and very limited 
capacity to meet the demand for inpatient beds. In addition, 
you would have noted a very high level of uncompensated care. 
Whereas approximately 3 percent of our inpatients at the 
downtown hospital lacked health insurance pre-Katrina, the 
corresponding rate has been as high as 47 percent post-Katrina. 
If insufficiently addressed, this high level of uncompensated 
care could well undermine the financial capacity, particularly 
of practitioners, but also of institutions, to meet their 
obligations.
    Turning to infrastructure, throughout Orleans Parish there 
is a major shortage of clinics, of inpatient beds, and of both 
acute care and nursing home beds. Our progress in rebuilding an 
effective health care system post-Katrina is moving far too 
slowly to meet the needs of current citizens and temporary 
residents, much less the anticipated health care needs, as New 
Orleans continues to repopulate over the next 12 months.
    This problem is being felt disproportionately in many of 
the areas of greatest need. As an example, there's not a single 
designated psychiatric bed in Orleans Parish today.
    Now let me talk a little bit about providers. Approximately 
3,200 physicians were practicing in the New Orleans 
metropolitan area prior to Katrina. Today it's not certain, but 
that number is thought to be somewhere between 1,400 and 1,600 
physicians, of which Tulane practitioners represent about a 
quarter. Federal estimates suggest that New Orleans has lost 77 
percent of its primary care providers, 89 percent of its 
practicing psychiatrists. Many of those who remain are finding 
it very difficult to meet their financial obligations. If we 
lose our remaining network of primary care physicians and the 
specialists, it's going to be very challenging and I might add 
very expensive to rebuild.
    Compounding this, we've had to reduce the size of our 
medical residency training programs post-Katrina. If this 
reduction in size persists into the future, one of the most 
reliable pipelines for the attraction of highly skilled health 
care practitioners to our region will be diminished.
    Today I ask for your support in reauthorizing important 
programs such as the Public Health, Security, and Bioterrorism 
Response Act. I strongly support Secretary Leavitt's 
recommendation that we redesign the health care system in 
Louisiana's Region 1. This to me is a long-term goal. In the 
short term, we need assistance to provide health care 
appropriate to the current needs of our community.
    In closing, let me say that I'm again very grateful you're 
here, that my colleagues and I, at Tulane, are fully committed 
to playing a leadership role in health professional training, 
in health care delivery, in promotion of wellness and economic 
revitalization of our community. I want to thank you for the 
privilege for being able to testify today.
    [The prepared statement of Dr. Whelton follows:]
                 Prepared Statement of Paul K. Whelton
    Mr. Chairman and members of the subcommittee, thank you for the 
opportunity to speak with you today regarding the public health 
recovery in the city of New Orleans since Hurricane Katrina's historic 
landfall on August 29, 2005. It is an honor to welcome you to our city. 
On behalf of our students, faculty, researchers, staff and patients, I 
would like to express our gratitude to you for coming to see our 
progress and challenges first-hand.
    I want to thank the subcommittee for supporting public health 
recovery efforts in New Orleans. We are particularly appreciative of 
Secretary Leavitt's commitment to the long-term recovery of our 
region's healthcare system. The support from Federal agencies such as 
the National Institutes of Health, the Centers for Disease Control and 
Prevention, and the Department of Veterans Affairs continues to be 
invaluable as we recover.
    We have made significant steps forward despite almost overwhelming 
challenges, but still have a long way to go before health care and 
public health preparedness in our city and region are robust enough to 
serve our current population--including temporary laborers and 
volunteers. Together, we must ensure the presence of a sustainable 
public health and healthcare system that meets both the routine needs 
of our region, as well as the needs of our population, during any 
future disasters.
         public health and medical care: the tulane commitment
    Tulane University was founded as a public-health-oriented medical 
school 172 years ago in response to community needs--epidemics of 
yellow fever, cholera and malaria. Except for 3 years during the 
American Civil War, Tulane University, which today includes its Health 
Sciences Center, School of Medicine, School of Public Health and 
Tropical Medicine, and hospitals and clinics, has served our community 
without interruption, including before, during and after Hurricane 
Katrina. Our commitment to the success of New Orleans began long before 
Katrina reached our shores and our resolve to be a vital part of the 
community's rebirth following the hurricane has never wavered. That 
commitment is sealed in our mission and in our hearts.
    Prior to Hurricane Katrina, Tulane University was the largest 
private employer in Orleans Parish. Today we are the single largest 
employer in the Parish and we remain one of the fastest-growing 
economic engines in southeastern Louisiana. Before Katrina, 
approximately 8,000 faculty, students and staff worked at the Tulane 
University Health Sciences Center. With more than 350 full-time faculty 
members, our medical group was one of the largest in the region 
overseeing care for approximately 1,000 inpatients and 50,000 
outpatients per month. Our medical and public health training programs 
were amongst the most competitive in the Nation. With annual research 
awards of approximately $140 million per year, a recent three-fold 
increase in awards from the National Institutes of Health, and evolving 
partnerships with other academic institutions in our region, Tulane 
supported a vibrant research and discovery community. We had an annual 
operating budget in excess of $650 million at the Health Sciences 
Center and Tulane University Hospital & Clinic, along with major 
additional responsibilities at the Southeast Louisiana Veterans Health 
Care System (Tulane provided approximately 75 percent of the physician 
services) and the Charity System Medical Center of Louisiana, New 
Orleans.
    Throughout and immediately after Katrina, Tulane faculty, students 
and staff remained to provide essential services. They performed 
admirably and many emerged as heroes who saved lives under extremely 
challenging conditions. Not a single life was lost at the Tulane 
University Hospital & Clinic. Our staff took whatever measures were 
necessary to save human lives, including hand ventilation of patients 
for prolonged periods when electricity was unavailable. In addition to 
safely evacuating all of our patients, faculty, staff, students and 
friends, we evacuated many of our research animals and humanely 
euthanatized those that could not be evacuated. Moreover, we preserved 
key cell lines for both clinical care and research, and vital 
equipment--saving U.S. taxpayers millions of dollars.
    In the immediate post-Katrina environment, Tulane was the largest 
ambulatory care provider in Orleans Parish, with clinics that remained 
open 7 days a week. Our medical personnel provided free care for about 
400 patients per day in the absence of any formal healthcare 
infrastructure. The majority of those who received care were uninsured 
or under-insured. Our faculty provided care under awnings, in police 
precincts, in tents, and in parking lots. Although we are a private 
institution, we remained true to our mission of meeting the healthcare 
needs of the community. Indeed, we are still operating the Covenant 
House clinic in the French Quarter, one of the four free clinics that 
we established following Katrina. In conjunction with the Children's 
Health Fund we established a mobile pediatric unit, still in operation, 
which has allowed us to serve children in their own neighborhoods 
without regard to their parents' ability to pay for the services 
rendered. Additionally, we were able to place our clinical faculty 
throughout Louisiana, focusing on the sites where New Orleanians 
evacuated in the diaspora, such as Alexandria, Baton Rouge, Lafayette, 
Pineville and the New Orleans Northshore-Covington area.
    The commitment of our healthcare professionals to helping the 
community has been extraordinary and universal amongst faculty, staff 
and students. As one of many examples, we, in conjunction with Common 
Ground, are running a special Latino Health Outreach Project Clinic on 
the West Bank section of the city. This clinic was the brainchild of 
Catherine Jones, a third-year student in Tulane's combined medical 
degree and master of public health degree program. Jones, a native of 
New Orleans, heard the distressing news--of uninsured, nonEnglish-
speaking day laborers--while an evacuee with her family in Texas. She 
immediately returned to Louisiana, and with the help of others provides 
free health care for up to 50 New Orleanians each day in an abandoned 
storefront in Algiers.
    On February 14, Tulane University Hospital & Clinic (TUHC) became 
the first hospital to reopen in downtown New Orleans following the 
hurricane. TUHC serves as a vital resource for repopulation of the 
city. The opening of the hospital was critical to assuring the success 
of this year's Mardi Gras and was a sign that the city was ready to 
welcome back both tourists and the business community.
    As reported by the Government Accountability Office in March 2006, 
63 beds were staffed in February at the downtown TUHC. Today, that 
number is 93, which represents a 48 percent increase in 5 months, but 
this is still only 40 percent of our pre-Katrina 235-bed capacity. 
Concurrently, we have been staffing approximately 60 beds at our 
Tulane-Lakeside Hospital in Jefferson Parish, which we reopened in 
October. This represents about half of the 119-bed capacity at that 
hospital.
    Through the summer, we have been adding outpatient clinics 
throughout the city and region. At our downtown campus, we have 
reopened emergency, urgent care, transplant and multispecialty clinics. 
The Tulane Cancer Center infusion and clinical treatment clinics are in 
the process of reopening, with cancer radiation therapy and other 
clinics planned to open in August.
    With much appreciated help from our colleagues in south Texas, we 
maintained the integrity and quality of our School of Medicine training 
programs. Likewise, with help from the other accredited schools of 
public health, we provided our public health students the opportunity 
to continue their studies at many of the Nation's best schools. Our 
School of Public Health and Tropical Medicine, the oldest in the 
Nation, restarted its educational programs in New Orleans in January. 
And as of last week, all of our medical students and medical residents 
have returned to the city. Medical students, and especially medical 
residents, often decide to stay and practice where they receive their 
medical education and training. Returning our trainees to New Orleans 
is a vital step in the rebuilding of the health professions workforce 
for our region. Also, the public health students who are enrolled at 
Tulane, and the many that stay after graduation, contribute to 
improving the community's health through public health outreach 
initiatives, education endeavors and research.
    While learning, our medical students and residents participate in 
clinical rotations and training programs that add to the clinical care 
resources of the city. We retained 98 percent of our medical student 
body. I am pleased to report that we were able to fill our residency 
slots for the 2006-2007 year with highly-qualified candidates--in most 
instances they were our first or second choices. Also, after receiving 
more than 7,000 applications for admission to our MD program 
(consistent with recent years' numbers), our incoming medical school 
class is among the largest in our history and has an academic profile 
congruent with prior entering classes. In addition to this, many have 
chosen Tulane because they want to participate in rebuilding the 
community's healthcare system. All combined, these promising results 
reflect the interest of young health professionals in providing care in 
a challenging environment.
    Before the storm, the city's medical district was an epicenter for 
the training of healthcare professionals, including more than 1,400 
medical residents. Tulane lost vital medical resident training 
positions due to the closure of the Charity System's Medical Center of 
Louisiana, New Orleans and the Southeast Louisiana Veterans Health Care 
System inpatient facilities in New Orleans. TUHC has helped by opening 
up nearly 50 additional temporary residency positions. Furthermore, we 
have placed medical residents at our Tulane-Lakeside Hospital in 
Jefferson Parish and several other hospitals in the community, 
including the Ochsner Medical Center, Touro Infirmary, West Jefferson 
Medical Center, East Jefferson General Hospital and Slidell Memorial 
Hospital. TUHC is negotiating a lease of approximately 40 beds to the 
VA--expected to become operational by October 1st. Not only will these 
beds help serve the needs of local veterans and their families who must 
now travel many miles for inpatient services, but they will serve as a 
vital part of our medical resident training program. Despite all of the 
above, it remains a challenge to find appropriate training environments 
for training of our medical residents.
    Despite research inventory and facilities losses of more than $120 
million, Tulane University remains the region's largest research 
enterprise and the area's only institution to be ranked in the top 100 
for receipt of awards from the National Institutes of Health. Last year 
the university received more than $140 million in research awards, with 
more than $110 million awarded to faculty at the Health Sciences 
Center, the largest in our history. I expect our health sciences 
faculty will end the year with awards totaling between $100 million and 
$105 million (90 to 95 percent of last year's total). Again, this is 
another example of our commitment to the region's economic recovery.
    Our School of Public Health and Tropical Medicine has assiduously 
monitored public health concerns and provided information through 
initiatives--from recovery issues to nondisaster health maintenance, 
e.g., nutrition and heart disease. Specifically, faculty from the 
Tulane Department of Environmental Health Sciences worked alongside 
Federal, State and local health officials to provide real-time guidance 
to community residents for pressing environmental health issues--from 
drinking water safety and air pollution to mold remediation. The school 
has retained more than 80 percent of its students and already has 
exceeded its goals for fall enrollment, with a similar academic profile 
to that of previous years. An exiting development last fall was the 
start of our new undergraduate program in public health, one of a few 
in the Nation. Already, enrollment has exceeded expectations and in a 
few years the program will produce young, vibrant public health 
professionals.
           public health and medical care: the key challenges
Fragmented Healthcare Infrastructure
    Currently, a safety net for the uninsured is lacking. The burden on 
hospital bed capacity, as well as the lack of financial support to care 
for this growing segment of the population, is seriously threatening 
the functioning and sustainability of what was already a fragile city 
public health and healthcare system. The loss of the Charity and VA 
system's inpatient capacity has exacerbated the situation. Accelerated 
in the aftermath of the storm and its related economic fallout, patient 
capacity to pay for health care has been greatly diminished. Before 
Katrina, the percentage of uninsured patients in New Orleans was 
already larger than the national average. At Tulane, the number of 
uninsured outpatients has risen from around 6 percent pre-Katrina to 
recent numbers of 20 percent for Tulane-Lakeside and 40 percent for 
Tulane University Hospital & Clinic. HHS funds to help 32 States 
shoulder increased medical costs attributable to Katrina had covered a 
fraction of Medicaid providers' costs at hospitals for claims of 
uninsured patients through Jan. 31. Also, the Louisiana Legislature has 
authorized financial support to Louisiana hospitals for care of 
patients without health insurance but this assistance does not address 
the financial plight of the physicians who provide the care. The bottom 
line is that (a) the funding directed to help hospitals is insufficient 
and (b) support is not reaching the individual healthcare providers and 
many, especially physicians, have made the decision to relocate to 
other regions of Louisiana or to other States. Many more are 
considering relocation. Compensation for care of uninsured patients is 
a growing crisis that could lead to further deterioration of our 
region's healthcare infrastructure.
    In addition to the financial challenges for healthcare 
professionals and healthcare systems, there is an acute shortage of 
clinics and inpatient facilities. This is disproportionately being felt 
in some key areas of need. For example, there is not a single 
designated inpatient psychiatric bed in Orleans Parish. In addition, 
when patients are discharged from hospitals there are few options 
available for homecare or institutional care, such as nursing homes. 
This has resulted in a prolongation of hospital stays by approximately 
20 percent--further exacerbating the shortage of inpatient beds and 
cost of care.
Loss of a Competent Healthcare Provider Workforce
    The considerably decreased patient base and permanent relocation of 
hundreds of physicians continues to significantly impair our 
community's ability to provide quality care. Repopulation cannot occur 
without a commensurate investment to retain and recruit physicians, 
nurses and other health professionals. Retention of physicians and 
public health professionals is already a problem and could get worse 
before stabilizing. This should be a very high priority. If we lose our 
network of medical professionals in New Orleans--which includes a mix 
of primary care physicians and specialists--it will be challenging and 
expensive to rebuild. Before Katrina, the Orleans Parish Medical 
Society estimated 3,200 physicians were practicing in Orleans, 
Jefferson and St. Bernard parishes. Today, they estimate the number is 
between 1,400 and 1,600 physicians, of which Tulane practitioners 
represent about one-fourth of those currently in practice.
Disaster Preparedness
    Public health and healthcare preparedness are integral to disaster 
readiness. Multi-faceted challenges, such as disaster recovery and 
preparedness, cannot be solved with monolithic solutions. While we need 
to look broadly and think long-term, my biggest immediate concern is 
for the middle phase of recovery--simplified, I'll refer to it as Year 
2. We have moved beyond the rescue and rebounding phase of Year 1. Now 
Federal emphasis is on long-term rebuilding starting in Year 3. I 
support the Department of Health and Human Services and Secretary 
Leavitt's redesign for Louisiana Region I. With Federal assistance, our 
long-term prospects look promising. My fear is for this gap between 
Years 1 and 3. The next 6 to 9 months are critical, and I am hoping 
that this subcommittee can help address this concern. By helping us 
now, you will further the understanding of this middle period of 
insecurity to the benefit of future disaster recoveries. The importance 
of a successful execution of this middle phase has been demonstrated 
internationally. For example, investment during this transition period 
after the Kobe, Japan disaster provided a critical foundation for 
subsequent long-term, sustainable recovery. Please keep our second 
post-Katrina year in mind and in motion.
            public health and medical care: looking forward
Assuring a Robust Healthcare Infrastructure
    In my opinion, a Federal policy for care of those without health 
insurance is much needed. This should be an immediate priority for New 
Orleans, because if unaddressed, it promises to undermine the capacity 
of the healthcare provider community to survive. In New Orleans, there 
appear to be three groups of uninsured patients: (1) residents who did 
not have insurance before Katrina; (2) residents who had health 
insurance prior to Katrina, but no longer do so, either because they 
lost their job or lack the resources to continue paying for their 
insurance; and (3) day laborers who are temporary residents and lack 
any form of health insurance. We need a better understanding of the 
relative contribution of each group and ways in which their acquisition 
of health care can be encouraged and facilitated.
Strengthening the Healthcare and Public Health Workforce
    Healthcare providers make choices to stay or leave a distressed 
community. In this context, it could be valuable to have a national 
registry of physicians, as well as other healthcare professionals. In 
addition to helping patients locate their providers, such a registry 
could help providers from unaffected areas who want to assist in 
recovery efforts. This concept not only creates surge capacity in a 
seamless fashion nationwide, but also comports with the Federal 
emphasis on regional preparedness. We could also utilize Public Health 
Service personnel to rebuild the healthcare infrastructure and to fill 
provider gaps as needed--current examples of need include nursing, 
mental health and dental health. However, while volunteers might be 
effective in the short-term, ultimately our community needs the 
stability and quality that comes from the long-term commitment of local 
providers.
    The ability to support healthcare providers is pivotal to retaining 
a competent clinical staff. I am grateful to the Board of Tulane and 
the university administration for ensuring that payroll and benefits 
were covered for our faculty, clinicians and medical residents, and to 
our clinical partners at HCA, who did an outstanding job in evacuating 
patients and staff and in helping to place them in jobs at other 
facilities. While we benefited from a temporary relaxation of the Stark 
law through 2005, there needs to be consideration of a national policy 
which extends that time frame in the aftermath of a disaster, so that 
hospitals and organizations with the resources can help doctors with 
housing and other accommodations. We, as a Nation, also need to 
consider bridge-income strategies for healthcare providers, beyond SBA 
loans and Medicare patches, which would be effective in retaining the 
healthcare provider workforce. This is an ever-growing concern as the 
cost of living and the cost of doing business continues to increase as 
a result of the post-disaster regional economic environment.
    Next, we need to enhance health professionals' knowledge of public 
health emergency preparedness. In maximizing Tulane's academic disaster 
expertise for public health and biodefense, starting this fall, our 
School of Public Health and Tropical Medicine will offer the Nation's 
only concentration in disaster management for a Master of Public Health 
or Master of Science in Public Health degree. The degrees will be 
offered both onsite and on-line, to help create a readiness workforce. 
Tulane will work to enhance the South Central Center for Public Health 
Preparedness and the South Central Public Health Training Center, which 
we launched in 2002, to serve the public health workforce in the four-
state region of Alabama, Arkansas, Louisiana, and Mississippi. In the 
2004-2005 year the South Central Center for Public Health Preparedness 
trained 17,550 and the South Central Public Health Training Center 
trained 6,965 professionals. For 2005-2006, the respective numbers 
exceeded 17,000 and 8,700. Training and education provided by these 
centers addressed critical disaster preparedness and response 
components such as Incident Command, Chemical Terrorism, and sessions 
specific to the lessons learned from Hurricane Katrina. Continued 
Federal support will help our efforts for first-time and continuous 
training of public health professionals and first responders: EMTs, 
police officers, fire fighters, nurses and doctors.
    Tulane took the lead in assuring disaster preparedness. Both the 
School of Public Health and Tropical Medicine and the School of 
Medicine have in place schoolwide emergency preparedness and response 
plans. Parts of the plan were successfully exercised through drills 
this spring. Now, every faculty member, staff and student can develop a 
personal preparedness plan to be executed in time of disaster.
The Public Health Security and Bioterrorism Preparedness and Response 
        Act
    The Public Health Security and Bioterrorism Preparedness and 
Response Act is an important vehicle to solidify collaboration of 
public and private sector resources. Specifically, the following 
programs are illustrative of the synergism between academia and 
government to assure frontline preparedness and response:

    a. CDC's public health preparedness grants for State health 
departments--These grants are vital mechanisms for disaster planning 
and response. Diminishing the commitment to this program will severely 
hamper Louisiana's and other States' abilities to respond to disasters.
    b. Centers for Public Health Preparedness--Funded through the CDC, 
this program is administered by the Association of Schools of Public 
Health and is a proven strategy for training first responders, medical 
personnel, public health specialists and EMTs. Of special note is that 
the center, led by the Tulane University School of Public Health and 
Tropical Medicine, provides life-long, just-in-case and just-in-time 
training and education to disaster personnel in four States including 
Mississippi, which also shares the threats of the Gulf Coast.
    c. HRSA's hospital preparedness program--Tulane participates in the 
regional system established by the State of Louisiana under this 
program. Having a primed regional hospital system will allow for 
critical surge capacity in times of crisis.
    d. Electronic database (ESAR-VHP)--While the funds are limited, 
Hurricane Katrina showed the real need for a database that facilitates 
advanced registration of health professionals, so that they can be 
mobilized at a moment's notice. Tulane will participate with the State 
in implementing this program.
    e. HRSA health professions terrorism training grant--While 
Louisiana was not a recipient under this grant program, the goal of the 
program to assure a cadre of trained public health professionals is 
just what we need to respond to terrorism and assure care during 
disasters.
    f. Expansion of the national stockpile--Tulane's hospitals 
participate in the stockpile program. Hurricane Katrina has 
demonstrated the importance of having the appropriate supplies--both 
accessible and tailored to local needs.
    g. City readiness initiative--The city of New Orleans currently 
does not participate in this initiative. However, the HELP Committee 
could consider the eligibility of cities like ours, even though the 
population size might not appear to substantiate the need. Having the 
funds provided through this initiative will make a difference in the 
readiness of our city.
               public health and medical care: conclusion
    Reinventing New Orleans' healthcare systems will prove vital to 
rebuilding the economy in New Orleans, as the two are interdependent. 
This is not a theory, but a proven correlation in models of developing 
countries. Rebuilding New Orleans' healthcare systems is not only 
essential for its region's residents, it is also valuable to Federal 
lessons for biodefense, as well as for re-inventing healthcare systems 
across the Nation.
    I ask that you consider New Orleans' impending needs for:

     Assuring we have a robust healthcare infrastructure, 
including provisions to help the uninsured.
     Strengthening our healthcare workforce, to allow for 
repopulation and economic recovery.
     Reauthorizing the Public Health Security and Bioterrorism 
Preparedness and Response Act and funding the programs, which will help 
for this and future disaster recoveries, as well as improved planning.

    Despite enormous challenges and financial losses at the Tulane 
University Health Sciences Center, we remain committed to preserving 
the integrity and quality of our educational, clinical and research 
programs, which result in great economic opportunities for the region 
and State. As the leader in disaster preparedness and recovery, the 
Federal Government should support institutions such as ours in 
maintaining their missions and serving as economic engines for their 
communities.
    The public health and medical care community in the New Orleans 
metropolitan area faces many serious challenges. However, with the 
support of the American people and through our public leaders such as 
those of you on this subcommittee, we will recover. My colleagues and 
I, at Tulane, are fully committed to the rebirth of our community and 
to working with you toward achieving a mutual goal of excellence in 
health care and disaster preparedness. Thank you.

    Senator Burr. Thank you, Dr. Whelton.
    Dr. Quinlan.
    Dr. Quinlan. Thank you. I'd like to open by saying that I 
endorse the comments made by my colleagues and especially by 
Dr. Whelton. I understand that the purpose of this is mainly to 
share our experience so that others won't have to have quite 
the same experience that we all did.
    With that, I'll dispense with my submitted testimony and 
share some additional ideas that I think are exportable, which 
remains a real lesson. Some things are local in nature, but 
this is something where there are a number of things that I 
think we could apply to any disaster.
    With regard to--I would say, though, parenthetically with 
what Paul just said, that if in fact there are 1,400-1,600 
clinicians left in the region, we have 550 of them. We're about 
a third. So about the sustainability question, there has been a 
rightful focus on redesign and improving things for the future. 
I think it's not only an opportunity, it's an obligation.
    But if there's no today, then we don't need to plan on 
tomorrow. We are suffering similar losses that Paul mentioned 
and our institutions are similar in that we're both private 
institutions, we're both private, not-for-profit, and we don't 
fit the categories of typical public assistance that some of 
our other colleagues do. So I would ask you, when you return to 
Washington, to please address that, because we get a great deal 
of sympathy but very little help. We are obliged and willingly 
will be up for the next disaster, but our ability to do so is 
becoming in question. So we need to focus on the today and we 
can talk about that offline in the future.
    As far as our perspective, we're a very large institution. 
We're the largest one in the State, about 1.1 million visits a 
year, lots of clinics, hospitals, etcetera. Our main campus is 
our anchor. We're about 15 minutes from this point. We're on 
the edge of Orleans Parish.
    Often in the discussion of New Orleans we confuse Orleans 
Parish with greater New Orleans. There are a few hospitals that 
have borne the brunt of this disaster and we are one of them. 
The U.S. Public Health Service used our board room as the 
command post on day one of the recovery or day two, and that 
was a very instructive vantage point. So the remarks I have are 
borne of our success when we stayed open.
    I have a good story to tell. I can speak from experience 
about what works and I can speak from experience from what I 
observed as the situation evolved with all the incoming 
agencies and players and what were impediments to success. I 
think these are some of the lessons learned.
    No. 1, about communication, I think everyone knows that the 
way to decapitate your opponent is first to destroy their 
communications in wartime. The same thing happens in peacetime, 
but the effect is the same. We kept our communications open. We 
have redundant buried T1 lines into our other sites, so we have 
a very large network that reaches into Baton Rouge and the 
north shore. So we retained our Internet capability and our 
phones and that was invaluable to understanding how to respond 
to the disaster.
    We also have a mature electronic medical record that knits 
our system together so that our patients when they did evacuate 
were able to get uninterrupted care. So I endorse the concept 
through experience of the importance of an electronic medical 
record.
    The key to our success was culture and it's a performance-
based culture with an emphasis on teamwork. We can't instill 
that everywhere in the country, but what you can instill it in 
is in the response teams from the various governmental 
agencies. They need to have a culture of performance and 
teamwork and the ability to integrate and do things 
differently, and we can talk about that.
    We heard other testimony about the idea, which we say is: 
expect to be alone, plan for a worst case scenario. I think 
most disasters are felt to be more finite in terms of your 
planning. Plan for the worst and if you're not ready for the 
worst then don't be surprised. We did plan for the worst and 
fortunately we were ready for this one, but we're under no 
illusion that we might be ready for the next one because by 
definition you're surprised. Otherwise it's not a disaster. But 
I think that we need to prepare for that.
    One of the things that we were prepared for that I would 
think needs to be part of all disaster preparedness is to 
provide for security. Fortunately, we had 20 armed guards so 
that our folks had a sense of security and were able to focus 
on their jobs at hand and not be distracted by concerns for 
their own safety or the safety of their colleagues or patients.
    Some of these things I'm going to talk about almost sound 
like platitudes, but I can tell you that if you don't practice 
them you'll lose a huge amount of emotional energy and actually 
engage in counterproductive behavior. That is, practice 
gratitude. We witnessed so many acts of kindness and generosity 
and courage by our people at Ochsner for the patients and 
families and so many nameless volunteers and donors from around 
the region and country. This was the untold story. Ninety-nine 
percent good news, 1 percent bad news. Unfortunately, we only 
saw the 1 percent bad news.
    Furthermore, take heart in the great number of highly 
competent, dedicated, and hard-working public servants at every 
level of government. In our focus on failures, we overlook the 
successes that were the product of exceptional effort and 
skill. At times our systems were simply not worthy of the 
people who served them.
    This is an important one: Cultivate curiosity, particularly 
in times of stress. We tend to miss what we don't know or don't 
anticipate or we try to force things into previous experiences 
that just aren't right. We tend to find what we're looking for 
and overlook what we're not, and we tend to see and hear what 
we believe. Catastrophe requires that we throw out old 
assumptions and think anew. We just need to know that 
catastrophes by definition are going to be different because 
the environment's different. We have to have people who are 
alert, who ask many more questions than talk, and that they're 
onsite and learn rather than just react.
    It's kind of a nebulous concept, but when you can see 
people who clearly did that they were successful. The people 
who came preloaded weren't. So it's an attitude and it gets 
back to the culture that we need to develop for first 
responders.
    We need to learn to practice patience. We have a democracy, 
which tends to be noisy and complicated. You can write the book 
on that. Our governments are restrained by a host of 
regulations and statutes, all of which are not completely 
clear, as you well know. This complexity is often exacerbated 
by the grey areas of authority.
    Not uncommonly in our lengthy experience, administrative 
and legislative bodies each contend that the other has the 
authority to act without action by the other party, resulting 
in gridlock or deadlock. A pressing need and a divided 
authority is a stressful combination, particularly for those 
onsite, and it requires a lot of patience and goodwill to sort 
this out.
    The next one is the most important one: Get onsite and stay 
there. The proper response depends upon on-site assessments. 
While there are very good reasons to headquarter away from 
disaster, these reasons are insufficient when contrasted with 
the need for timely and accurate information and good 
leadership. You live by the principle that if you aren't there 
you simply don't know, and if you don't know you can't 
criticize, you can't judge.
    I cannot tell you how many times I heard countless people 
rolling through on a telephone trying to get up to speed, 
getting it partially right, and then moving on. It took a very 
complex and difficult situation and made it nearly impossible. 
It's a small wonder that anything got done, given the 
fragmented nature of this approach. People, even as they become 
to this day knowledgeable in their particular job, be it at 
FEMA or anything else, sometimes you have some very good ones 
and just when they're up to speed their rotation is over and we 
start over again. That is not the way to run a disaster of any 
size. That's fine for a tornado. It will not work for the next 
giant earthquake. It won't work for a bioterrorist incident, I 
promise you that.
    The other is, as I mentioned, stop the revolving door. 
During the crisis and post-crisis, rotating assignments were 
common. Just as they became knowledgeable, they were replaced. 
Common remarks are: I just didn't understand, and there's a 
gulf of understanding between X and here, be it Washington or 
Baton Rouge. Consistency will improve a difficult situation. 
Inconsistency will make it worse.
    The punch line here is: Use the private sector. We talked 
about stockpiling things. Don't bother for the most part if 
it's going to be of real scale. In government only the armed 
services are trained and configured for operations with both 
speed and scale. Until you've done something logistically, you 
don't understand. This is huge. Nobody's ready for it, and the 
next one could be bigger. The rest of government is best suited 
for maintenance and marginal change.
    That's the nature of our government by choice, by training, 
by configuration, by temperament, and with limitations of 
regulations and statutes that are incapable of rapid large-
scale response. We need to recognize that as the reality and 
plan differently.
    Private enterprise was and is collectively capable of 
massive, timely response. We are a production economy, we are a 
supply chain economy. We need to tap that.
    If we don't, shame on us; we won't be ready for the next 
one.
    This was our clear experience. We suggest that a public-
private partnership for a large-scale disaster response is the 
most successful option for the future. You need to become a 
manager and manage distribution. Do not get in the storage 
business. You won't be ready. Industry is very good at that.
    We need to harness it. Do not try to reinvent it. We can't 
afford it, simply.
    This collaboration should be formalized and built to a 
scale sufficient for the worst case scenarios. If we can access 
the capabilities of the private sector, we will achieve 
success.
    Finally, consider the incentives and counterincentives 
presented to all players. Our institution, Paul's institution, 
others have stepped up, borne the expense, stepped in for 
government at every level. However, the incentives simply 
aren't there. In fact, when you look at it there are counter-
incentives. Our business interruption insurance was greatly 
compromised by the fact that we fought successfully to stay 
open, and in response there has been nothing but thanks. Now, 
that's a side story, but the point is around the country if you 
expect private institutions to stand up, much like you will 
mobilize the private sector for supply and sustainability, you 
need to make sure that that's actually a common sense, 
straightforward thing to do, rather than being put in some sort 
of double bind where if you do the right thing you'll pay and 
in fact jeopardize your own existence.
    So I hope those things are helpful and I think every one of 
those are exportable and was applicable to our situation and 
will be to others. Thank you.
    [The prepared statement of Dr. Quinlan follows:]
                Prepared Statement of Patrick J. Quinlan
    Good afternoon, Mr. Chairman. I am Patrick J. Quinlan, M.D., Chief 
Executive Officer, Ochsner Health System (OHS), in New Orleans, La. I 
appreciate the opportunity to speak to you and your colleagues about 
the current state of healthcare in the greater New Orleans area, and 
the potential for re-building and re-designing our healthcare sector.
    For nearly 60 years, OHS has cared for residents in the greater New 
Orleans and Baton Rouge communities. Our main campus, including the 478 
acute-care bed hospital and clinic, is located in Jefferson Parish, 
less than a mile from the Orleans Parish line and only a 15-minute 
drive to downtown New Orleans. In addition, we have 24 clinics 
throughout the New Orleans area and a sub-acute nursing facility/
inpatient psychiatry/inpatient rehabilitation hospital two miles from 
our main campus. In Baton Rouge, we have three clinics, 70 physicians 
and 50 percent ownership of an acute care hospital. Recognized as a 
center for excellence in research, patient care and education, OHS is a 
not-for-profit, comprehensive, independent academic integrated health 
care system, and the largest nongovernmental employer in Louisiana. 
With more than 7,400 employees--including more than 600 physicians in 
nearly 70 medical specialties--OHS is also one of the largest 
nonuniversity-based physician-training centers in the country, annually 
hosting over 325 residents and fellows, 450 medical students and 400 
allied health students.
    When Hurricane Katrina hit the Gulf Coast, no one could have truly 
imagined the intense devastation it would leave in its wake. The wind 
and the rain wreaked havoc across Alabama, Mississippi and Louisiana. 
The health care system as we knew it in New Orleans was devastated. The 
universities responsible for 70 percent of the medical education in the 
State were closed. Knowing that the storm was headed their way, 
hospitals began sending home patients deemed well enough to be 
discharged. Those in critical condition or requiring special 
assistance, such as ventilator-assisted breathing, remained in the 
hospital. When hospital staff emergency teams arrived for work during 
the weekend before the storm hit, they expected it might be only a few 
days before they were able to return home. However, when the levees in 
New Orleans broke, the situation changed dramatically. We, and our 
colleagues in the New Orleans metropolitan area, faced a dire situation 
beyond our imagination.
    Throughout the onslaught of Hurricane Katrina, and during its 
devastating aftermath, OHS remained open, caring for patients and 
continuing our medical education programs. This afternoon, I would like 
to tell you how my hospital system prepared for the storm; what our 
facilities did to ensure our doors remained open to provide critical 
health care services to our community; what we have done subsequently 
to ensure continued provision of all critical health care needs to the 
community; how we have maintained medical education for the region; and 
answer any questions you and your colleagues might have about our 
experience.
                         planning for disaster
    Hospitals routinely plan and train to deal with disaster, whether 
it's the derailment of a train carrying hazardous substances, a 
multiple-vehicle accident on a nearby interstate, a plane crash, or a 
natural disaster such as a hurricane or earthquake. As hospitals plan 
for disasters and the prospect of going without public services such as 
electricity and water, we prepared to be on our own for at least 72 
hours, in the event it takes that long for assistance to arrive from 
the State or Federal Government. Our plan, which we revise after every 
disaster or ``near-miss'' event, had been revised most recently on June 
1, 2005, less than 3 months before Hurricane Katrina struck.
    On Friday, August 27, our entire executive leadership team had 
assembled in New Orleans for the first day of a 2-day leadership 
retreat. Late in the afternoon, we were notified that the storm had 
turned to the West and likely would strike the area. We immediately 
initiated the first phase of our disaster plan, which included 
notifying essential personnel and securing previously stockpiled 
supplies.
    Under the most recent disaster plan, two teams of essential 
personnel, Teams A and B, were created to ensure continuity of care and 
relief for employees on duty at the time disaster strikes. Each team 
was to include staff members from all departments, e.g. security, 
housekeeping, dietary, nursing, physicians, house staff, IT, media 
relations, research, etc. Team members had been identified and 
committed by June 1.
    From previous experience, we realized the importance of not only 
adequately stocking essential supplies onsite, but also creating a 
back-up system to ensure additional supplies could be secured in times 
of an emergency. On Friday, we activated our supply chain and began to 
secure the additional supplies we had stockpiled off-site. Important 
supplies included: 400 flashlights; 100 head lamps; 2,000 batteries; 
4,000 glow sticks, including 2,000 with lanyards; 600 SpectraLink 
wireless telephones with 1,800 batteries; 450 oscillating fans, one per 
patient; 250 box fans for work and sleeping areas; 20 55-gallon drums 
of water on each floor for commode flushing; 3000 gallons of water for 
drinking (we also have a deep water well on campus with a 10,000-gallon 
holding tank for additional water in an emergency); 60,000 gallons of 
diesel fuel; 10 pallets of sandbags; 8 pallets of plastic bags; 100 
blue tarps; 20 dehumidifiers; 5 pallets of plywood; and 50 additional 
shop vacuums. We also increased our food supply. At this time, we 
inspected our power sources. Our emergency generators are all located 
above our facility's second floor and our transformers were located on 
the ground level, behind 10-foot floodwalls.
    On Saturday, August 28, executive leadership met with the vice 
presidents, directors, and managers and agreed to order Team A onsite 
by Sunday afternoon. Staff then began discharging the appropriate 
patients and moving those that would be unable to leave the facility. 
The families of the remaining patients were given ``boarding rules''--
one family member per patient would be allowed to stay. Similarly, 
staff was discouraged from bringing family members to work unless they 
absolutely could not make other arrangements. All patient and personnel 
families were pre-registered and given ``special'' parking passes to 
access our parking garage. During previous storms, we experienced 
problems with people in the community attempting to use our garage to 
protect their cars and boats. Under the revised plan, we stationed 
armed guards at the entrances to the garage to ensure that hospital 
staff, patients and their families could access the garage, and that 
all entrances were kept clear.
    On Sunday, ``sleeping'' assignments were made. Due to concerns 
about the predicted high winds, patients were removed from the highest 
floors of the hospital. Patients were also moved into hallways and 
rooms without windows to protect them in the event of flying glass. 
Because OHS is a research facility, we house numerous research animals, 
which were evacuated to facilities in northern Louisiana. After 
evacuations were complete, we settled in to wait and see what Hurricane 
Katrina would bring.
                          weathering the storm
    Ochsner's main campus survived the actual hurricane quite well. We 
sustained some roof and structural damage to our main facility, but 
overall the news was positive. Our generators functioned properly, the 
Internet was up and running, and our internal communications system was 
fully operable. Employees lost cellular phone and beeper capabilities 
due to damage to local cell towers; however, we had planned for such an 
event, and staff members were armed with SpectraLink wireless 
telephones. As a result, communication critical to patient care was 
uninterrupted. Our land-based telephones also remained in working order 
due to redundancy in our carrier network. Our medical record system is 
entirely electronic, and with power and the Internet operable, we did 
not have concerns about the availability of critical patient 
information. We had adequate supplies and believed we would be able to 
ride out the next few days.
    However, as the situation in and around New Orleans rapidly 
deteriorated with the breach of the levees, conditions inside the 
hospital also took a turn for the worse. On the second day, one of our 
generators failed due to a mechanical problem, and we were forced to do 
without air conditioning. As a result, our Internet servers were shut 
down to prevent them from being damaged by the heat. Unfortunately, 
server shutdown meant the electronic medical record system was 
inoperable. We attempted to send our helicopter out to secure the 
needed parts for the generator, but all nongovernmental aircraft were 
temporarily grounded. We were, however, able to locate the necessary 
parts the next day to get the generator up and running again.
    Conditions in our immediate area continued to worsen. Our main 
facility is located a few miles from the I-10/Causeway where large 
numbers of people attempting to make their way out of New Orleans after 
the storm congregated. Many of those gathered turned to the hospital 
for assistance on their way. However, we are a hospital, not a shelter. 
We tried to point people in the right direction to get the help they 
needed, and also dispatched medical personnel to the site to care for 
individuals in need, transferring those needing hospitalization back to 
our campus. Conditions in our neighborhood further destabilized as 
floodwaters began to rise; looting of nearby businesses began. At that 
point, we felt compelled to ask the National Guard to assist us in 
securing the safety of our patients and staff, and placed OCF on 
lockdown.
    Operations inside the hospital similarly were beginning to show 
signs of strain. Although we had made extensive plans for securing and 
relieving essential personnel with the Team A and B designations, and 
had gone to great lengths to keep staff apprised of the situation--
setting up a telephone tree as well as a dedicated Web page with 
information--we had difficulty securing relief staff. Many had 
evacuated with their families to Baton Rouge and beyond. Fortunately, 
we were able to locate a good portion of staff members there and bring 
them in by bus convoy. As the floodwaters continued to rise, the same 
convoys were used to evacuate exhausted staff and their families, as 
well as patients who could be moved and their family members, to our 
facilities in Baton Rouge. These same convoys were our lifelines for 
supplies as well, enabling us to continue functioning.
    At their height, the floodwaters rose as far as the doors on one 
side of the hospital, but we maintained the ability to leave and enter 
the building from other entrances and faced no real danger. Instead, we 
realized that rumor and speculation were a larger threat to the 
internal stabilization of the hospital than the floodwaters, and 
created an internal communication system to keep staff and patients 
informed of the conditions within the hospital and the city at large. 
The leadership team met twice daily to be updated and then fanned out 
across the facility, sharing the news they had just heard and answering 
questions. This open and honest communication policy went a long way 
toward assuaging staff and patient fears, and keeping the hospital in a 
calm state.
    Toward the end of the crisis, we began to run low on food. However, 
we had an ample supply of water and were able to make do until relief 
shipments could be brought in. We also ran low on insulin, but because 
our telephones had been unaffected, we were able to secure 10,000 doses 
donated from sanofi-aventis pharmaceutical company.
                       reaching beyond our walls
    With the situation in OHS' main facility well in-hand, our 
leadership team sought to inform local officials and offer assistance 
to other health care facilities hit harder by the storm. Since our 
land-based telephone system was operable, we believed this would be 
easy. However, we had great difficulty trying to contact other 
hospitals and local agencies that were not as fortunate in the quality 
of their communications systems. We even found it difficult to locate 
the proper State and Federal officials to offer our assistance.
    According to our regional emergency plan, we report to the 
Jefferson Parish Office of Emergency Preparedness (OEP). However, the 
OEP system was overwhelmed and communication was impossible. When our 
attempts to reach the Jefferson OEP failed, we attempted to reach the 
Baton Rouge OEP. This was also challenging, as it appeared that the 
bandwidth of their system could not accommodate the high volume of 
incoming requests and was overloaded. We eventually successfully 
contacted the Orleans Parish OEP following the levee break, requesting 
both information, as well as assets. During this exchange, we became 
aware of their communications difficulties with the downtown hospitals 
that were in the midst of evacuating.
    It was virtually impossible to coordinate air evacuation due to the 
various agencies involved--both military and civilian--and their lack 
of ability to communicate. We sent a vice president through the 
floodwaters downtown to the Orleans OEP with a hand radio to try and 
assist their coordination efforts, but were unsuccessful in reaching 
them. We instead found a widespread lack of coordination: police 
communication systems that were ineffective due to infrastructure 
damage and volume, and a National Guard system that was able to 
facilitate communications amongst guard units, but had difficulty 
communicating with local authorities. Of external communications, 
satellite systems were unreliable, and cell service, for a while, was 
virtually eliminated. Text messaging and Internet were the most 
reliable methods of communication.
    Communication improved on day four when the United States Public 
Health Service (USPHS) arrived, and interagency daily meetings at OHS' 
main facility began. In addition to the USPHS, these meetings included 
``all'' hospitals and representatives from the Jefferson and Orleans 
OEP health care divisions. The USPHS was able to facilitate requests 
through the previously frustrating channels. They were particularly 
helpful with things like fuel and security; however, they did not have 
access to many of the assets we required. Prior to the USPHS's arrival, 
we were so frustrated in our inability to notify authorities that we 
were open and able to accept patients, that we used large trash bags to 
spell ``OPEN'' on our garage roof hoping to attract the attention of 
the armada of helicopters flying overhead.
                                recovery
    With our Board's permission, and because of our commitment to the 
community, and at a great expense to Ochsner, we have kept our 
workforce on payroll throughout and after the immediate crisis. We have 
recruited to fill both professional and nonprofessional positions in 
order to be able to open approximately 100 additional beds to serve the 
needs of the community. We have leased one of our facilities, the 
Elmwood Medical Center to the State to be used as a Level I trauma 
center. Even as our indigent care discharges have nearly quadrupled and 
our cost of operations has escalated, we have re-dedicated ourselves to 
be the healthcare safety net for the region. Despite operational losses 
of nearly $70M, we have maintained all of our primary, tertiary and 
quaternary services, including state-of-the-art cancer treatment, solid 
organ transplant, and cardiovascular interventions. We have received 
virtually no financial relief for our efforts and to offset our losses. 
Because we are a private not-for-profit institution, we have not been 
eligible to directly receive loans from the Community Disaster Loan 
program. HRSA grants, similar to what was offered to NYC institutions 
following the 9/11 disaster, have not been made available to us.
    We have also become the academic safety net for the region. Shortly 
after the hurricane, we invited investigators from both Tulane and 
Louisiana State Universities to use our research laboratory facilities 
in order that their research could continue uninterrupted. This has 
allowed numerous investigators from both universities to not only 
maintain their NIH funded work, but also to secure additional funding.
    Our teaching programs have continued uninterrupted. We had a very 
successful match for our residencies programs this year. Despite, our 
concerns of top students not wanting to continue their training in New 
Orleans, all of our programs filled at approximately the same or 
improved level from prior years. We even increased our match numbers by 
5 this year, despite the State offering a $10,000 bonus to students who 
matched into the competing University programs.
    Since we have an extensive infrastructure for academic activities, 
we have offered to host additional LSU and Tulane-based residents and 
medical students at our facilities. We are doubling the number of 
medical student rotations to over 900 annually. At this time, it 
appears we will have 50 to 75 additional residents training at our 
institutions. We are doing this even though it imposes a significant 
financial risk to us. The April ruling by CMS for temporary transfers 
of CAP FTEs during a disaster intends to ameliorate the financial 
burden. However, there are two aspects that significantly adversely 
affect our ability to host the residents. The ruling that the 
additional CAP transfer positions must be averaged over a 3-year period 
will have us not breaking even until the third year. At this time, when 
our cash flow is a significant issue, given our operating losses 
secondary to the hurricane, it is problematic that we will be able to 
continue to host the residents. Additionally, the 3-year maximum time 
period is significantly short of the time it will take for LSU and 
Tulane to restore their teaching facilities.
    The training of these house staff is critical to the New Orleans 
region being able to maintain an adequate public health workforce. 
Prior to the hurricane, the Louisiana Medical Education Commission has 
reported that Louisiana was in a relatively steady state in regards to 
the training and establishing of new physician practices relative to 
the number of physicians leaving practice. With large numbers of 
physicians having left New Orleans after the hurricane, any threat to 
the New Orleans region training programs will significantly affect the 
public health workforce and the ability to care for the healthcare 
needs of citizens in this region. Therefore, it is extremely important 
that the 3-year rolling average be abolished and the 3-year maximum 
time limit for this emergency ruling be extended.
    As you undoubtedly will learn from the LSU and Tulane 
presentations, the universities will be scrutinized extensively this 
summer by their accrediting bodies. Both the Accreditation Council for 
Graduate Medical Education (ACGME) and the Liaison Committee for 
Medical Education (LCME) will evaluate the respective residency 
training programs and medical school curricula. It is imperative that 
the medical schools demonstrate adequate teaching sites and supervision 
for both the residents and the students. If not, they will lose 
accreditation, faculty will leave, and students and residents will not 
be trained in their programs locally. The development and deployment of 
an appropriate public health workforce will not occur. This will result 
in the worsening of what already is a crisis.
    One of the success factors for Ochsner during and immediately after 
the hurricane has been our electronic medical record. This is the only 
fully functioning electronic medical record in the region. This was and 
continues to be a life saver for our patients. No matter where they 
arrived after the hurricane, their health record was available to them. 
This type of record is of paramount importance for all of our 
residents, whether in the midst of a disaster or in the course of their 
routine care. Because we recognize this, we have been working with 
local and State groups in the planning of health information technology 
for the region. We offer the use of our electronic medical record to be 
used by other institutions and patients in the region. The ability to 
make this available will require funding to adapt it to other 
institutions' platforms.
                         summary and conclusion
    Ochsner Health System is a nonprofit (501c3) independent academic 
integrated health care system. We have stayed open during the hurricane 
and expanded our ability to care for patients and maintain the academic 
programs in New Orleans. This has occurred at great financial impact to 
us. We have as of yet received no significant financial assistance to 
offset our losses. Our academic activities have allowed the two 
universities to return to New Orleans, and so far to remain in 
compliance with their accrediting bodies. Our electronic medical record 
is unique in the region and has been the lifeline for our patients.
    As you help to plan and oversee the rebuilding of healthcare in 
this region, we ask you to consider:

     Stabilizing the public healthcare workforce by asking CMS 
to amend its April Emergency Ruling to void the 3-year rolling average 
and 3-year time limit on the Cap transfer positions;
     Securing the availability of necessary healthcare services 
by assisting us in identifying funding to offset our hurricane-related 
operating losses;
     Ensuring the availability of patients' medical records 
during a disaster, as well as, for routine care by assisting the 
implementation of our electronic record for all providers regionally.

    We look forward to working with this committee and staff to forge 
ahead toward a shared goal of improving the healthcare in New Orleans.

    Senator Burr. Dr. Quinlan, thank you, and let me assure you 
that your points on logistics has been a primary focus of the 
subcommittee as we've looked at what the future should look 
like, and I wish I could assure you that I had all the answers. 
Logistics will always be a challenge, but we have heeded 
everybody's advice that the private sector must be included in 
that process or it will not work, and I agree.
    Dr. Rouse.
    Dr. Rouse. Thank you. I'm a 31-year-old psychiatrist, born 
and raised in New Orleans. I'm not here to detail grand 
recovery plans or report on any comprehensive programs that I 
oversee, because I don't oversee anything. I'm a whistleblowing 
psychiatric foot soldier and my sole intent today is to report 
accurately what I have seen and experienced from the very front 
lines of the medical and psychiatric response to Hurricane 
Katrina and to ask of you three things.
    When the storm hit, I had already evacuated with my wife 
and two small children to Houston. But when I saw the images of 
my home town on television I had to get back. I rushed back to 
Baton Rouge, volunteered in the extraordinary field hospital 
set up on LSU's campus. Then with medical supplies, my 
backpack, and frankly my firearm, I broke back into my home 
town and offered medical and psychiatric assistance to the 
members of the New Orleans Police Department, and I was quickly 
commandeered.
    Along with a Homeland Security medic, we set up a medical 
and respite clinic for NOPD and Federal law enforcement 
personnel in the gift shop of the Sheraton Hotel downtown, 
using whatever supplies we could scrounge. We worked for a week 
straight, nights and days, providing badly needed medical 
support to the rescue workers who braved the rancid flood 
waters.
    However, we were starkly alone. Promises of medical 
reinforcement from the United States Public Health Service were 
only promises. Nearly a week after the storm, while the Baton 
Rouge field hospital was closing down, volunteer doctors were 
being turned away by FEMA, while we were still screaming for 
assistance. Scientologists, Tom Cruse's cult, were in New 
Orleans providing massages before we saw any organized Federal 
medical help with the NOPD. In my sleep-deprived eyes, there 
was a crisis and organized help was merely a wish.
    Now, 10 months after the storm, I'm not working any more as 
an ad hoc emergency room doctor, but as the deputy psychiatric 
coroner for Orleans Parish. What that means is under Louisiana 
law I provide medical-legal oversight over involuntary 
psychiatric commitments and I assist families in getting 
treatment for persons potentially dangerous to themselves or 
others because of psychiatric illness.
    I can state unequivocally that now, with respect to mental 
health, we are in no less of a crisis than I faced in that week 
after the storm. In fact, mental health is the chief public 
health problem facing our area in my somewhat shrill opinion 
right now.
    Let me present to you the grim facts regarding our mental 
health situation in the greater New Orleans area. The suicide 
rate spiked dramatically after the storm. In Orleans Parish, 
conservative estimates suggest a tripling of the per capita 
suicide rate through the end of 2005. Estimates from nearby 
Jefferson Parish also suggest increased suicide rates and 
attempted suicides during this time period. Most of these 
people had no previous history of emotional or psychiatric 
difficulties.
    My boss, the Orleans Parish coroner, Dr. Frank Minyard, 
estimates that the effects of ongoing psychological stress 
account for as many deaths as the direct effects of Katrina. 
This is especially relevant to our elderly population and 
locals will tell you that the obituary pages in our newspaper 
are noticeably longer.
    At the coroner's office we are committing more patients per 
capita than we ever did before the storm, and as the months 
tick on more and more of these patients we deem especially 
dangerous, such as having access to weapons or a history of 
fighting with law enforcement. Unfortunately, local law 
enforcement has been forced to use deadly force three times on 
the psychiatrically ill since the storm, something that was 
virtually unheard of before the storm.
    The NOPD and other local law enforcement agencies are 
spending an inordinate amount of time handling calls for 
service regarding the mentally ill. This overwhelming demand on 
our law enforcement community drains precious resources at a 
time when proactive community policing is most necessary. Every 
officer that sits in an emergency room for hours and hours with 
a psych patient is one less officer available to my community, 
to my wife, and my two small children at home.
    Hospital security at several of the institutions 
represented before you today refused to take custody of these 
patients on arrival to the emergency room, in my nonlegal 
opinion a likely violation of State and Federal law.
    Studies have shown that increased use of illegal drugs and 
alcohol is rampant in our communities, and we've lost about 89 
percent of our psychiatrists, as you've already heard. Budget 
cuts have forced both Tulane and LSU departments of psychiatry 
to lay off about half of their faculty at this time of greatest 
need. The remaining local outpatient psychiatric providers have 
seen dramatically increased caseloads and they have been heroic 
and creative in finding ways to deliver quality mental health 
care under the current circumstances. However, the treatment 
options for the suicidal, the drug addicted, or the violent 
psychiatric patient are a most critical need.
    The metropolitan New Orleans area had approximately 450 
psychiatric inpatient beds before the storm and now we have 
about 80. Tulane DePaul Hospital, a large Columbia HCA-managed 
psychiatric hospital in uptown New Orleans, lies mostly 
undamaged, but empty, reportedly because of financial concerns. 
Patients now wait in emergency rooms for psychiatric placement 
for days and days, often confined to isolation rooms with 
medication treatment only. Emergency rooms are inundated with 
these psych patients. Veterans with need for psychiatric 
hospitalization to this day are shipped as far away as Houston, 
and there are no public detoxification services currently 
available for drug addiction in the local area. We have a 
critical psychiatric bed shortage. We are now New York without 
Bellevue, Washington, DC., without St. Elizabeth's, and North 
Carolina without John Olmstead in Butner.
    Now, in this time of greatest need I paint this picture to 
ask you three simple things. No. 1, for the sake of my State 
and for any communities affected by future disasters, please 
amend the Stafford Act. As it's written, FEMA is prohibited 
from funding any direct mental health activities that are 
considered psychiatric treatment. I think we've learned that a 
disaster of this magnitude demands a Federal response flexible 
enough to assist all of its citizens in all capacities, 
including the mental health effects that I just listed.
    As specified in the Stafford Act, the provision of, quote, 
``crisis counseling'' by those without mental health training, 
it's simply not sufficient. If a dirty bomb contaminates 
Manhattan or San Francisco experiences a major earthquake, you 
can be assured that our experience of a post-Katrina mental 
health crisis will unfortunately be repeated. Please remove 
this arbitrary prohibition. We lost many of our local health 
workers due to budget cuts when we needed them most, because of 
this limitation.
    No. 2, if you are going to have a strategic national 
stockpile, please add psychiatric medication to it. It's not in 
there currently and inevitably you will have people who need 
continuation of existing psychiatric medication as well as 
assistance in basic things such as sleep and anxiety reduction 
during this stressful time.
    Then finally, on behalf of the mental health, the law 
enforcement, the criminal justice, and the emergency room 
communities of this area, I ask the subcommittee to put its 
full weight of its power to force the State of Louisiana 
Department of Health and Hospitals, the LSU Health Care 
Services Division, and the Office of Mental Health to abide by 
its moral and legal obligation to re-open its full-scale acute 
psychiatric emergency room for the New Orleans metropolitan 
area. There's already a Federal consent decree known as the 
Adam A decree issued in the early 90s. This forced the State to 
have a behavioral health emergency room. This 25-bed 
psychiatric emergency room on the third floor of Charity 
ensured timely and appropriate mental health treatment for the 
acutely psychiatrically ill and for those suffering from drug 
abuse. First responders could bring patients there and be back 
out on the streets within 15 minutes.
    Now the New Orleans area is faced with a behavioral public 
health emergency of unprecedented magnitude and we do not have 
the capacity to care for the suicidal and the psychotically 
violent. The third floor of Charity or DePaul Hospital, in my 
frank opinion, could be reopened right now with these two keys 
right in front of me and the current mental health crisis in my 
home town would be dramatically and rapidly mitigated.
    We're a year after Katrina. Current plans from the State 
with regards to a psychiatric emergency room remain tentative 
at best, likely underfunded, and call for as few as six beds.
    There are six psychiatric patients waiting in the halls of 
just one local emergency room right now.
    As I felt during the immediate aftermath of the storm, 
there is still a crisis in my home town and organized health 
remains merely a wish. Please put pressure on this issue from 
the top down and enforce the full spirit of the Adam A consent 
decree. For future disasters, I urge you to maximize and 
augment psychiatric care and learn from the bitter lesson we 
are still enduring. It's a matter of public health, public 
safety, and society's obligation to care for its ill, including 
the mentally ill.
    Thank you.
    Senator Burr. Dr. Rouse, thank you, not just for your 
testimony but for the way you responded personally to the 
disaster here. It was our intent as we introduced the public 
health legislation that the Stafford Act would be one of those 
areas we would address. Washington is a strange town 
jurisdictionally and sometimes it's tougher when you produce 
legislation that crosses different committee jurisdictions. It 
will not be part of this effort, but let me assure you the 
committee is working with those two committees of jurisdiction 
to make sure we look at that issue very seriously.
    Dr. Rouse. Thank you.
    Senator Burr. Mr. Barry.
    Mr. Barry. Thank you. First of all, I'd like to thank the 
subcommittee for traveling here to Louisiana to conduct your 
hearings here. We appreciate that very much. For me it's a 
personal privilege to appear before you this afternoon to share 
what I might regarding what Katrina and Rita have taught us 
about our vulnerabilities.
    As you mentioned, I am President and CEO of Blue Cross-Blue 
Shield of Louisiana. We're the manager of medical benefits for 
just over 1 million people in the State of Louisiana, which 
represents about half of those who do have private health 
insurance.
    Unlike my colleagues on the panel, I want to make it clear 
I was not involved in any on-the-ground operations related to 
patient care during or after the hurricane. My observations are 
drawn primarily from the vantage point of assisting those 1 
million Blue Cross members in securing the health care services 
that they needed during the immediate crisis and what has 
proved to be a very long and painful aftermath.
    But that has meant working closely not just with those 
members, but, just as importantly, with care providers. We've 
also worked closely with their employers and with the agents 
and brokers who serve them.
    I'd like to speak briefly about the public health side of 
Hurricanes Katrina and Rita. We've all seen those televised 
images of the hurricanes' physical and emotional toll on the 
citizens of our State. Those are seared into our consciousness 
and the comprehensive histories of Katrina and Rita have 
already been written and they need no embellishment here. But 
from a public health standpoint, as you've heard from my 
colleagues, there is a very important aspect of Katrina's and 
Rita's legacy which, while less obvious, is perhaps even more 
important. And that legacy is that of people's inability to 
access critical health care services when needed and the 
inability of caregivers to provide the care that is most 
appropriate.
    While these issues existed to some degree before the 
hurricanes, they turned extraordinarily acute after the 
hurricanes, teaching us what I see as four very important 
lessons, lessons which, as you've already heard, continue to 
this day taking an immense toll on public health. We are still 
learning these lessons.
    Lesson one, that a metropolitan area's health care capacity 
is easily overwhelmed. We've spoken already about the surge on 
health care demand, and it wasn't simply the loss of hospital 
infrastructure. As you've heard from other people on our panel, 
a number of doctors and nurses have also left the area and, 
while the area is smaller in population than it was before in 
terms of residents who have left and have still gone, by our 
reckoning looking at our claims data doctors and nurses have 
left the area in even greater proportions.
    We would also indicate that, based upon what we're seeing, 
that about three-quarters of the physicians who had been 
practicing in the New Orleans area are no longer submitting 
claims to us, so that they clearly have left this area, leaving 
it grossly underserved in our view.
    Lesson two, something you've also heard a little bit about 
already: that logistical and communication issues make it 
difficult to even properly use what limited health care 
capacity has remained. In the period immediately following 
Hurricane Katrina, many needed and willing medical 
professionals already within the area or coming into the area 
were not engaged due to credentialing and licensing issues, 
fears of professional liability, or lack of centralized 
coordination.
    There was also obviously a loss of contact between 
physicians and the ill patients that they were attending prior 
to the hurricanes, rendering appropriate clinical follow-up 
with these patients impossible. Normal referral patterns among 
independent practitioners have also been thoroughly disrupted 
with the migration of so many doctors, leading to disruptions 
and patient care.
    Surprisingly, there is no centralized information or 
database from which patients or referring physicians can even 
determine or public health planners can determine which nurses 
or which doctors have remained in or have returned to the 
affected areas.
    Resource shortages in certain key areas within the system 
are creating bottlenecks in the care continuum, for example, 
the inability to discharge hospitalized patients due to 
shortage of home health care nurses needed for follow-up; the 
excess demand on area emergency departments due to shortages in 
primary care.
    Lesson three, the widespread loss of patient records put 
large numbers of patients at risk. Dr. Cerise had spoken about 
that in his remarks. There were efforts made to help remedy 
that situation immediately after the hurricanes. Through 
katrinahealth.org, our own organization quickly put together a 
patients claim-based health record which has a lot of valuable 
information for attending physicians to use in the care of 
those patients who left their communities or even left the 
State.
    In practice, those efforts and those capabilities did not 
garner as much physician uptake as one would have hoped and we 
believe the reason is that we were missing the requisite 
provider awareness and education that's required to utilize 
these tools. So we need to anticipate not just having those 
types of tools available, but using tools such as that have to 
become part of clinical practice for them to be effective.
    Lesson four, and I'd like to spend just a little bit of 
time on this because I think it's a point that can't be 
overstressed, although a number of my colleagues have made 
comments with respect to it, and that is that the normal 
methods of reimbursement which health care providers rely on 
are very easily disrupted in an event such as Hurricanes 
Katrina and Rita. For example, during the height of the 
emergency and its aftermath, providers were preoccupied with 
meeting immediate patient needs and not with gathering patient 
documentation which would later be needed to submit claims, 
particularly in the case of Medicaid patients and the 
uninsured.
    Some of the unique aspects of health care financing in 
Louisiana, particularly the dependence on the, quote, ``charity 
system'' for indigent care and our heavy dependence on Medicaid 
and disproportionate share of funding, created unanticipated 
systemic vulner-
abilities. Closure of LSU's Big Charity Hospital left LSU 
Health Services and Tulane and LSU Schools of Medicine without 
their normal revenue source. Charity's closure significantly 
increased the percentage of uninsured and Medicaid patients 
treated by other hospitals in the area, which are not normally 
compensated for providing those services, or at least not on 
the same basis.
    We're seeing that prolonged impatient lengths of stay due 
to these difficulties in discharging are creating losses on 
Medicare-based DRGs. Independent physicians, particularly those 
serving the Medicaid population, face difficulties maintaining 
their practices due to the dispersion of their former patients 
and lack of critical mass in most neighborhoods for developing 
new patient bases, which makes it difficult for them to come 
back.
    Surprisingly, we've seen that private insurance has so far 
remained resilient to Katrina-induced demographic and economic 
disruption. Of more than--we have more than 800,000 of our 
members who are covered under group insurance plans and so far 
we've only seen a loss of about 30,000 because of people who 
have lost their employer-provided coverage. We expect that is 
going to continue to go up as some businesses who are 
struggling to maintain operations over time may not be able to 
do so.
    One of the things that we found worked with regard to the 
privately insured process is that we granted a 90-day grace 
period for premium payments, and we continue to pay full 
reimbursement for all medical services provided to all of our 
patients regardless of whether premiums were paid, and we saw 
that that provided a very important bridge to those customers 
to be able to live through the crisis and, surprisingly, the 
great majority of those who suspended those premium payments 
came through and made those payments in December. So there has 
been much more resilience in that private insurance customer 
base than we would have thought, which has been helpful in 
helping to support the remaining capacity that we have in the 
New Orleans area.
    However, we are seeing that our claim level in the New 
Orleans area has been somewhat modestly reduced, which is 
testimony to the compression that exists within the health care 
system because of the excess demands being placed on it and the 
lack of full access to privately insured patients is further 
compromising the financial integrity of the system that 
remains.
    We're also seeing a lot of workers who are coming in and 
the rebuilding efforts are not covered, not only for private 
health insurance, but they don't have workers compensation 
coverage, and those uninsured workers who have come into the 
area are also creating a burden for our hospital 
infrastructure.
    I do have a set of several recommendations. In the interest 
of time, I would just like to emphasize, I think a lot of these 
issues that we've pointed to do have solutions, but they 
require thoughtful solutions. Some of those need immediate 
attention. One of the recommendations as we think about 
emergency preparedness that would be easily overlooked is the 
need to have a quick response in the immediate aftermath of the 
disaster, to have a coherent public policy response that 
involves public sector and private sector to deal with the 
emerging immediate issues that no one can anticipate on the 
heels of such a devastating event, so that we get in front of 
these issues and that the toll does not linger to the degree 
that it has here in our area.
    Thank you very much.
    [The prepared statement of Mr. Barry follows:]
                    Prepared Statement of Gery Barry
                              introduction
    First, I'd like to thank the subcommittee for traveling to 
Louisiana and for conducting your hearings here. Being on the ground 
and witnessing first hand our long road to recovery will itself provide 
you with invaluable insights as you think about how to protect our 
communities from large-scale external threats to public health and 
healthcare. It's a privilege for me to appear before you this afternoon 
to share what Katrina and Rita have taught us about our 
vulnerabilities.
    I'm President and CEO of Blue Cross Blue Shield of Louisiana. I 
moved to Louisiana from Connecticut to assume this position just 10 
months before the hurricanes hit. More recently, I have served as chair 
of the Health Systems Redesign Workgroup under the Louisiana Recovery 
Authority. This effort has now evolved into the LA Healthcare Redesign 
Collaborative chaired by Dr. Fred Cerise, Secretary of Department of 
Health and Hospitals.
    To give you context for my observations, let me take a minute to 
give you some background on our company. We are a traditional Blue 
Cross organization. By that I mean we are an exclusive statewide Blue 
Cross Blue Shield licensee, governed by a local board of directors. We 
are a not-for-profit, but tax paying organization owned by our 
policyholders. We employ about 1,400 Louisianians. We are the manager 
of medical benefits for just over 1 million of Louisiana's 4.4 million 
residents, representing just about half of those with private health 
insurance.
    My observations are drawn from the vantage point of assisting our 
one million members in securing the healthcare services they needed 
during the immediate crises and this long and continuing aftermath. 
This has meant working closely with not just these members, but just as 
importantly, their care providers. We have also worked closely with 
their employers and with our agents and brokers who serve them. Having 
said that, my observations are personal ones and do not necessarily 
reflect those of our company or of the Redesign Collaborative.
The Public Health Side of Hurricanes Katrina and Rita
    Televised images of the hurricanes' physical and emotional toll on 
the citizens of South Louisiana are already seared into our 
consciousness. Comprehensive histories of Katrina and Rita and their 
immediate aftermath have already been documented and need no 
embellishment here. However, from a public health standpoint, there is 
an aspect of Katrina's and Rita's legacy which, while less obvious, is 
even more important. This legacy is that of peoples' inability to 
access critical healthcare services when needed and the inability of 
caregivers to provide care that is most appropriate.
    While these issues existed to some degree before the hurricanes, 
they turned extraordinarily acute after the hurricanes, teaching us 
four very important lessons.
    lesson 1.--a metropolitan area's healthcare capacity is easily 
                              overwhelmed
     Pre-Katrina, the New Orleans area, by almost any measure, 
appeared to have excess clinical capacity, at least in terms of in-
patient beds, nursing home beds, and clinical specialists. Katrina's 
decimation of the health system created an unexpected shortage.
     Katrina's toll on the healthcare capacity in the New 
Orleans area was swift and deep. Only 3 out of the 15 or so hospitals 
in the area remained open throughout the ordeal.
     Shortly after the hurricane, shock waves of excess demand 
for healthcare services spread quickly throughout the State as evacuees 
from the affected areas arrived, many in need of care.
     Today, most of the hospitals in the New Orleans area 
remain closed, including Big Charity. Those few that have since 
reopened (e.g., Tulane) are operating at reduced capacity.
     While many area residents left and are still gone, doctors 
and nurses who had been practicing in the New Orleans area left in even 
greater proportions. Based on Blue Cross Blue Shield of Louisiana 
claims data, about three quarters of the some 4 thousand independent 
physicians who were practicing in Orleans, Jefferson or St. Bernard 
parishes prior to Katrina remain unaccounted for, i.e., have not 
submitted claims since the hurricane.
     According to many service providers on the ground in the 
New Orleans area, the per capita need for healthcare has increased 
significantly due to hurricane-related causes (mental health, 
accidental injury and stress-induced increases in morbidity). This 
surge occurred without the spike from potential hurricane-related 
disease outbreaks that some had feared. Thank goodness.
  lesson 2.--logistical and communication issues make it difficult to 
         properly use the limited healthcare capacity available
     In the period immediately following Hurricane Katrina, 
many needed and willing medical professionals already within the area 
or coming into the area were not engaged due to credentialing or 
licensing issues, fear of professional liability and the lack of 
centralized coordination.
     Loss of contact between physicians and the ill patients 
they were attending prior to the hurricanes rendered appropriate 
clinical follow-up with these patients impossible.
     Normal referral patterns among independent providers have 
been thoroughly disrupted, leading to disruptions in patient care 
itself.
     There is no centralized information or database from which 
patients or referring physicians can determine which nurses and doctors 
have remained in or have returned to the affected areas.
     Resource shortages in certain key areas cause bottlenecks 
throughout the care continuum, e.g., the inability to discharge 
hospitalized patients due to the shortage of home healthcare nurses 
needed for follow-up.
lesson 3.--the widespread loss of patient records put large numbers of 
                            patients at risk
     Paper medical records housed in affected physician offices 
were entirely destroyed.
     Many ill patients who evacuated left without their 
medications or prescriptions.
     Doctors and hospitals in surrounding areas who were seeing 
many patients for the first time had little or no patient medical 
history or other pertinent information to go on as they were treating 
these patients.
     Post-hurricane efforts to reconstruct meaningful medical 
record proxies either through claim histories (as done for Blue Cross 
Blue Shield of Louisiana members) or through pharmacy data (as done 
collaboratively through katrinahealth.org) were technically successful; 
in practice, they did not garner much uptake at the time as the 
requisite provider awareness and education could not be achieved in a 
timely manner.
    lesson 4.--the normal methods of reimbursement which healthcare 
                 providers rely on are easily disrupted
     During the height of the emergency and its aftermath, 
providers were preoccupied with meeting immediate patient needs and not 
with gathering patient documentation which would later be needed to 
submit claims, particularly in the case of Medicaid patients and the 
uninsured.
     Some of the unique aspects of healthcare financing in 
Louisiana, particularly the dependence on the ``Charity'' system for 
indigent care and our heavy dependence on Medicaid and 
``Disproportionate Share'' funding, have created unanticipated systemic 
vulnerabilities. Some examples:

          Closure of LSU's Big Charity Hospital left LSU Health 
        Services and Tulane and LSU Schools of Medicine without 
        significant revenue sources.
          Charity's closure significantly increased the 
        percentage of uninsured and Medicaid patients treated by other 
        hospitals in the area which are not normally compensated for 
        providing those services.

     Prolonged inpatient lengths-of-stay due to difficulties in 
discharging are creating losses on Medicare-based DRGs.
     Independent physicians, particularly those serving the 
Medicaid population, face difficulties maintaining their practices due 
to the dispersion of their former patients and the lack of critical 
mass in most neighborhoods for developing new patient bases.
     Private insurance has so far remained resilient to 
Katrina-induced demographic and economic disruption. Of the more than 
800,000 whose group insurance is provided by Blue Cross Blue Shield of 
Louisiana, about 30,000 have lost their employer-provided coverage. 
Lapse rates in individually purchased coverage have been lower than 
normal. However, per capita claims levels in the immediate hurricane-
affected areas have remained somewhat lower (10 percent) than expected, 
due apparently to the compression on the healthcare delivery system for 
the reasons stated above. For providers, this reduction in services to 
privately-insured patients, while modest, adds to their financial 
strain.
     Many new workers in the New Orleans area are arriving at 
hospitals needing medical attention, but are uninsured even for 
workers' compensation.
                               conclusion
    To respond appropriately to a major communitywide or regional 
disaster, whether natural or man-made, we must overcome the systemic 
weaknesses exposed by Katrina and Rita. In redesigning our health 
system in Louisiana following the hurricanes, we have the opportunity 
to build a new system that is sufficiently flexible and adaptable in 
the face of disasters. Specifically, we need to:

     Insure reliable, real time communication capabilities 
exist among first responders, government officials and the many 
involved in the management and delivery of healthcare for the immediate 
and surrounding area;
     Establish plans in advance for networking with other 
clinical resources, both those in the area and those from out of the 
area, to establish capacity for dealing with a surge in demand 
following a disaster-induced shut down in clinical capacity in the 
immediately affected area;
     Better communicate and integrate the efforts of all 
parties, public and private into the immediate emergency response;
     Quickly and effectively coordinate public policy follow-up 
to resolve acute and structural issues associated with the aftermath of 
the disaster;
     Establish electronic patient health records for everyone;
     Maintain a real time electronic registry of healthcare 
professionals in the area with complete tracking of those moving into 
or leaving the area;
     Redesign public reimbursements for health care services to 
make sure they work for all providers delivering care during and 
following a disaster;
     Consider requiring businesses involved in the affected 
area's redevelopment to provide workers' compensation and health 
insurance benefits to their workers;
     Provide temporary support to people losing their employer-
provided health insurance through a mechanism such as the Health 
Coverage Tax Credit available to those losing their jobs under 
international trade agreements.

    Thank you for your kind attention. I would be happy to respond to 
any questions you might have.

    Senator Burr. Mr. Barry, thank you, and thank you, to all 
the witnesses, not only for your information, but for your 
ability to modify the schedule that we had and to accommodate a 
much shorter period. I can assure you that I think each one of 
you and every member who's here from the U.S. Senate could 
spend a day together with you sharing the first-hand 
information that you've gone through.
    It strikes me just how well each one of you has a handle on 
what you've been through, where you are today, but more 
importantly where you need to get to. That has not gone 
unnoticed, I will assure you.
    I wish I could sit here today and tell you that we could 
produce one piece of legislation in Washington that would 
address all of the issues that you have raised, and if I said 
that you would know it to be disingenuous. We can't do that. 
But we're attempting to begin the process and over some period 
of time we will hopefully be able to address the meat of what 
has been raised.
    Those that will benefit from it are not only New Orleans or 
Louisiana; it will be communities that are faced with very 
similar degree of disasters and tragedies in the future that 
won't have the challenges that you have had here.
    This is an official hearing and for that reason I will 
assure you all written testimony will be made a part of the 
record without objection.
    It's important that you know, in addition to Senator 
Landrieu, myself, and Senator Alexander, we're joined today by 
over 50 staff members from additional members of the HELP 
Committee in Washington. Typically we would take a period of 
time to pose questions to you and solicit those answers. For 
the purposes of this truncated process, I'm going to ask all of 
you, if you would, to be open to written questions. Give us the 
opportunity to go back with the testimony that you've provided 
for us. It would help us to ask questions that might be of more 
value to both of us. And if you would, in as timely a fashion 
as you find it able to do, respond to those questions for the 
committee.
    I want to once again thank Senator Landrieu and Senator 
Vitter. If it wasn't for these two individuals I'm not sure 
that Washington would have had the attention. I reminded Mary 
as I came up, North Carolina had a rather significant storm, I 
think now 6 years ago. It involved a tremendous amount of 
flooding. This year we put the last people into permanent 
housing, 6 years later.
    I don't want to suggest that I know the magnitude of what 
you've gone through. I know how the next crisis of the day 
overshadows the last one, and when you're in the community that 
was affected everybody forgets and focuses on what just 
happened. What your Senators have been able to do is to keep 
Washington focused on the fact that there was a disaster, there 
is still a problem, and there continues to be a need for 
Washington to address on an ongoing basis the challenges that 
you're faced with. Let me assure you that we do recognize that 
need.
    Once again, I thank the Senators for joining me. I thank 
you for testifying.
    Senator Landrieu. May I ask just one question?
    Senator Burr. You may certainly.

                 Opening Statement of Senator Landrieu

    Senator Landrieu. Thank you all so much for your patience 
today, but also the forcefulness in which and the 
professionalism in which you give this testimony. This is a 
story that must be told. And I know you've told it many times 
and you've told it again today, but we need to continue to tell 
it so that we can get the response that we need: No. 1, to 
continue to address the nightmare that many of us, all of us, 
are still going through here; to help the people that are in 
this region and this city and this State.
    But as you all stated, we don't want to see this ever 
happen to anyone again. So the testimony that you're giving 
will help all the government structures, all the private sector 
structures, all the faith-based organizations, all the 
professionals, to know what needs to be done so that we can try 
to prevent this kind of suffering and catastrophe from 
happening again. So I just wanted to thank you all very much.

                 Opening Statement of Senator Alexander

    Senator Alexander. Let me add my thank-you, and I'm going 
to preside over the transition from Health to Education.
    But if all of you will permit me a personal word first, 
this is a very distinguished panel and I know you all are 
extremely busy. You had other things to do today and because of 
our schedule you had to change yours. We thank you for that. We 
understand how busy you are.
    Second, the personal note is this: Literally 40 years ago 
this moment, I was a law clerk to Judge John Minor Wisdom in 
this building. I was actually a messenger. He already had a law 
clerk and he wanted two, so he promised to treat me as a law 
clerk. And I lived here for a year on Felicity Street, and I 
was making so little money that I played in a washboard band on 
Bourbon Street at Your Father's Moustache, which burned down 
about 15 years ago, which may have had something to do with the 
music there.
    But this brings back a lot of memories to me. I believe 
this was the old Wildlife Fisheries Building at one time, and I 
came here every single day. So this brings back a lot of 
memories.
    Thank you very much for coming, and now I'd like to invite, 
apparently------
    Senator Burr. Lamar, before you do that. Without objection, 
I would ask that the record be kept open for 10 days for 
additional questions and answers.
    Senator Alexander. Now we will shift from Senator Burr's 
subcommittee to the Subcommittee on Education and Childhood 
Development. I believe the entire first panel that was to be 
here at 9:30 has waited until now, so I'd like to invite them 
to come forward to the table and we'll begin with them.
    [Whereupon, at 3:05 p.m., the subcommittee was adjourned.]