Gain­ing in New Orleans

With help from a fed­eral grant, wounded city builds a model pri­mary-care sys­tem

Modern Healthcare - - Cover Story -

Four years ago, an in­te­grated pri­mary-care sys­tem that pro­vides ac­cess to high-qual­ity care to New Orleans res­i­dents in their own neigh­bor­hoods was nearly un­think­able. To­day, as a new re­port from the not-for-profit Com­mon­wealth Fund shows, not only is that sys­tem a re­al­ity, but also it might serve as a model for the rest of the na­tion to fol­low.

In 2007, the sys­tem was made pos­si­ble by a $100 mil­lion grant from the fed­eral gov­ern­ment that has helped the city of New Orleans re­build its bro­ken health­care sys­tem fol­low­ing Hur­ri­cane Ka­t­rina. But when that grant money ends later this year, health of­fi­cials and providers fear that the new sys­tem—which has pro­duced pos­i­tive re­sults—won’t be able to sur­vive.

Be­fore the storm hit in Au­gust 2005, unin­sured res­i­dents in New Orleans re­ceived care pri­mar­ily at the LSU Health Sys­tem’s Char­ity Hospi­tal, the cen­ter of the city’s large safety net hospi­tal sys­tem known as the Med­i­cal Cen­ter of Louisiana at New Orleans. Se­vere flood­ing and dam­age forced Char­ity’s clo­sure, and the city’s in­pa­tient bed ca­pac­ity dropped by more than 50%, while the num­ber of am­bu­la­tory clin­ics fell to 19 from 90. Mean­while, about 4,500 physi­cians were dis­lo­cated tem­po­rar­ily, and about 35% of those were pri­mary-care physi­cians, the re­port said.

Two years later, HHS awarded the state a $100 mil­lion Pri­mary Care Ac­cess and Sta­bi­liza­tion Grant, re­ferred to com­monly as the PCASG, which ends in Oc­to­ber. In grant­ing the money, the fed­eral gov­ern­ment chose the not­for-profit Louisiana Pub­lic Health In­sti­tute to ad­min­is­ter the grant and work with fed­eral, state and lo­cal part­ners. Since then, the health­care sys­tem lit­er­ally has been trans­formed into an ex­pand­ing net­work of in­de­pen­dent, neigh­bor­hood pri­mary-care clin­ics. The grant was awarded to 25 or­ga­ni­za­tions, which in turn op­er­ate 93 sites (be­sides clin­ics, there are also mo­bile-health units). Of those sites, the Com­mon­wealth Fund con­ducted in­ter­views at 27 grant-sup­ported sites in 2009 to eval­u­ate their progress. As the study shows, the re­sults are more than promis­ing.

“When you com­pare na­tional rates with what we found with the clinic pa­tients, pa­tients were very sat­is­fied with the care that they re­ceived,” said Michelle Doty, as­sis­tant vice pres­i­dent at the Com­mon­wealth Fund and one of the lead au­thors of the re­port. “The level of pa­tient-doc­tor com­mu­ni­ca­tion was re­ally ex­cel­lent. The vast ma­jor­ity of peo­ple found their doc­tor un­der­stood them and their med­i­cal his­tory,” she said, adding that pa­tients also had an easy time get­ting an ap­point­ment. “We’re see­ing a re­ally high level of pa­tient-cen­tered care. I found that sur­pris­ing, given that the ma­jor­ity of th­ese pa­tients are re­ally low-in­come and unin­sured and his­tor­i­cally this level of qual­ity of care isn’t re­ally seen in th­ese types of pop­u­la­tions.”

Data for the study—con­ducted from early Fe­bru­ary 2009 un­til early April 2009—came mostly from the Com­mon­wealth Fund 2009 Sur­vey of Clinic Pa­tients in New Orleans, an in­per­son sur­vey that an­a­lyzed a sam­ple of 1,573

clinic pa­tients aged 18 or older or adults ac­com­pa­ny­ing a chil­dren un­der the age of 18. The twopart sur­vey in­ter­views last about 20 min­utes and were con­ducted at 27 PCASG-sup­ported pri­mary-care and pe­di­atric clin­ics across Orleans Parish in New Orleans. Ac­cord­ing to the re­sults, 88% of pa­tients re­ported hav­ing easy ac­cess to care; 79% said they had ex­cel­lent com­mu­ni­ca­tion with their physi­cians; and 86% of re­spon­dents with chil­dren rated pa­tient­clin­i­cian com­mu­ni­ca­tion highly. In ad­di­tion to pa­tients, physi­cians ap­pear sat­is­fied with the new sys­tem.

“It’s far and away the best struc­ture I’ve had to man­age,” said Karen DeSalvo, ex­ec­u­tive di­rec­tor of Tu­lane Com­mu­nity Health Cen­ters, which has two com­pre­hen­sive, pri­mary-care sites and three mo­bile­care units. “The teams are hap­pier; the pa­tients are get­ting good care.”

There are sev­eral rea­sons for the pro­gram’s suc­cess, ac­cord­ing to DeSalvo. Th­ese in­clude med­i­cal school loan­re­pay­ment pro­grams, which pro­vide an in­cen­tive for new physi­cians to choose pri­mary care; in­te­grated ser­vices—in­clud­ing pri­mary care and men­tal health—in the same lo­ca­tion; and, per­haps most im­por­tant, a pay­ment struc­ture that al­lows the money to fol­low the pa­tient.

“From the dev­as­ta­tion emerged an op­por­tu­nity to re­struc­ture and re­or­ga­nize pri­mary care for low-in­come and vul­ner­a­ble pop­u­la­tions in New Orleans,” said Melinda Abrams, as­sis­tant vice pres­i­dent at the Com­mon­wealth Fund and the study’s other lead au­thor. Ac­cord­ing to Abrams, one key el­e­ment of suc­cess has been the strong part­ner­ship be­tween the sites and the Louisiana Pub­lic Health In­sti­tute, which she said has cred­i­bil­ity with the pri­mary-care sites; ap­plies com­mon re­port­ing mea­sures; brings the clin­ics to­gether; and of­fers fi­nan­cial in­cen­tives for care de­liv­ery. Clay­ton Wil­liams had served as di­rec­tor of health sys­tems de­vel­op­ment for the in­sti­tute and over­saw the fed­eral grant process that es­tab­lished the new sys­tem. On Jan. 19, Wil­liams will be­gin his new role as the as­sis­tant sec­re­tary for the Louisiana Health and Hos­pi­tals Depart­ment.

As Wil­liams ex­plained, the PCASG grant had four clear goals: to in­crease ac­cess to care; to pro­vide ev­i­dence-based, qual­ity care; to es­tab­lish an organized sys­tem of care; and to de­velop sus­tain­able busi­ness en­ti­ties. Two years af­ter the grant was awarded, of­fi­cials and providers have achieved those goals.

“We’ve seen the num­ber of de­liv­ery ser­vice sites grow from 67 to 93; we’ve seen vol­ume grow by over 50% over the past two years,” Wil­liams said, adding that about 175,000 in­di­vid­u­als have been treated at the 93 sites over two years. Mean­while, there has been what Wil­liams calls a “dom­i­nant rise” in physi­cian avail­abil­ity, and the pub­lic health in­sti­tute im­ple­mented poli­cies that re­quired same-day vis­its for pa­tients need­ing ur­gent care as well as 24-hour ac­cess to a physi­cian by phone.

In terms of qual­ity, there were two com­po­nents, Wil­liams said. First were the re­quire­ments the in­sti­tute es­tab­lished re­gard­ing ac­cess to care, and the sec­ond el­e­ment was $4 mil­lion that the in­sti­tute set aside as in­cen­tives for those clin­ics that ex­ceeded the min­i­mum re­quire­ments. The in­sti­tute also worked with the Na­tional Com­mit­tee for Qual­ity As­sur­ance to al­low the sites to ap­ply to be­come pa­tient-cen­tered med­i­cal homes. An in­di­ca­tion of the sys­tem’s suc­cess in qual­ity is that the NCQA has rec­og­nized 40 of the 93 sites as pa­tient-cen­tered med­i­cal homes.

Es­tab­lish­ing an organized sys­tem of care had been a goal be­fore Ka­t­rina, Wil­liams said, and the in­sti­tute con­tin­ued this ef­fort with the new in­te­grated sys­tem. “We’ve cre­ated GNOCom­mu­ for pa­tients to go and seek ser­vices,” he said. “It al­lowed all of the clin­ics to have a site for re­fer­rals: clin­ics use it; pa­tients use it,” he added. “More im­por­tant, agree­ments were bro­kered among the health­care providers and the pub­lic hospi­tal,” he said, adding that re­fer­rals and in­for­ma­tion-shar­ing have al­lowed the neigh­bor­hood pri­mary-care clin­ics to re­fer their pa­tients for di­ag­nos­tic test­ing even if the clinic isn’t af­fil­i­ated with a par­tic­u­lar hospi­tal.

For the fi­nal goal—de­vel­op­ing sus­tain­able busi­ness en­ti­ties—Wil­liams said the pub­lic health in­sti­tute made sure early in the process that the sites had the ca­pac­ity to bill third-party in­sur­ers “so they’re not leav­ing any money on the ta­ble.” He ac­knowl­edged that the fed­eral fund­ing has been cru­cial to help­ing th­ese providers, many of whom have unin­sured pa­tient lev­els as high as 50% or 60%. Ac­cord­ing to Wil­liams, the sites can­not be sus­tain­able without some help. “The nee­dles are all mov­ing in the right di­rec­tion,” Wil­liams said. “We’re still con­cerned about the fu­ture.”

The fu­ture is a worry for physi­cian Don Er­win, CEO of St. Thomas Com­mu­nity Health Cen­ter, one of the grant re­cip­i­ents and also rec­og­nized as a med­i­cal home. Ac­cord­ing to Er­win, about 75% of St. Thomas pa­tients are unin­sured, and about 14% are Med­i­caid pa­tients.

“It’s go­ing to be a real game-changer if that money goes away,” Er­win said. “We have about a $4.5 mil­lion a year bud­get; $3 mil­lion comes from the PCASG grant,” he added. “If we had 40% Med­i­caid, we’d be OK. We may have 40% Med­i­caid in two years, if there is en­hanced el­i­gi­bil­ity,” he said, re­fer­ring to a pos­si­ble re­sult of a fi­nal health­care re­form bill from Congress. But what could hap­pen to St. Thomas un­til then could be “pretty scary,” Er­win said.

“Clearly, one of our big­gest con­cerns is that about $30 mil­lion a year that has been flow­ing into th­ese clin­ics will dis­ap­pear,” said Tony Keck, deputy sec­re­tary at the Louisiana Health and Hos­pi­tals Depart­ment. “The clin­ics have at­tracted more Med­i­caid and pri­vate-pay pa­tients,” he added. “Even with those im­prove­ments, there is still a gap in how money flows into the sys­tem.” To ad­dress this prob­lem, the de­part- ment is ex­plor­ing a few al­ter­na­tives, such as seek­ing fi­nan­cial as­sis­tance from the state, a pos­si­ble one-time grant with re­main­ing funds from the Louisiana Re­cov­ery Au­thor­ity, or a dis­pro­por­tion­ate-share hospi­tal waiver that would al­low funds to be in­jected not just to the pub­lic hospi­tal, but to the pri­mary-care sys­tem.

De­spite the con­cern about fu­ture fi­nanc­ing, the pri­mary-care sys­tem that has evolved in New Orleans since Ka­t­rina has yielded enough pos­i­tive out­comes—in terms of ac­cess, qual­ity care, and pa­tient and physi­cian sat­is­fac­tion—to be con­sid­ered a model for con­gres­sional leaders as they work to­ward a fi­nal health re­form bill.

“As we get closer to health­care re­form and uni­ver­sal cov­er­age, we need to find a way to quickly ex­pand ca­pac­ity and qual­ity of pri­mary care,” Wil­liams said. “Com­mu­ni­ties are go­ing to ask: ‘If we have more peo­ple with ac­cess to care, how will we ac­com­mo­date that de­mand?’ ” he added. “We’ve shown how—if there is ad­e­quate in­vest­ment.”

Wil­liams: “The nee­dles are all mov­ing in the right di­rec­tion.”

Doty: “We’re see­ing a re­ally high level of pa­tient-cen­tered care.”

Keck: “There is still a gap in how money flows into the sys­tem.”

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