Hurricane Katrina: Federal Grants Have Helped Health Care Organizations Provide Primary Care, but Sustaining Services Will Be a Challenge
Published: 2009-12-03T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The greater New Orleans area--Jefferson, Orleans, Plaquemines, and St. Bernard parishes--continues to face challenges in restoring health care services disrupted by Hurricane Katrina which made landfall in August 2005. In 2007, the Department of Health and Human Services (HHS) awarded the $100 million Primary Care Access and Stabilization Grant (PCASG) to Louisiana to help restore primary care services to the low-income population. Louisiana gave PCASG funds to 25 outpatient provider organizations in the greater New Orleans area. GAO was asked to testify on (1) how PCASG fund recipients used the PCASG funds, (2) how recipients used and benefited from other federal hurricane relief funds, and (3) challenges recipients faced and recipients' plans for sustaining services after PCASG funds are no longer available. This statement is based on a recent GAO report, Hurricane Katrina: Federal Grants Have Helped Health Care Organizations Provide Primary Care, but Challenges Remain (GAO-09-588), other GAO work, and updated information on services, funding, and sustainability plans, which we shared with HHS officials. For the report, GAO analyzed responses to an October 2008 survey sent to all 25 PCASG fund recipients, to which 23 responded, and analyzed information related to other federal funds received by PCASG fund recipients. GAO also interviewed HHS and Louisiana Department of Health and Hospitals officials and other experts.
section_title: What GAO Found
paragraphs: PCASG fund recipients reported in 2008 that they used PCASG funds to hire or retain health care providers and other staff, add primary care services, and open new sites. For example, 20 of the 23 recipients that responded to the GAO survey reported using PCASG funds to hire health care providers, and 17 reported using PCASG funds to retain health care providers. In addition, most of the recipients reported that they used PCASG funds to add primary care services and to add or renovate sites. Recipients also reported that the grant requirements and funding helped them improve service delivery and expand access to care in underserved neighborhoods. As of September 2009, recipients used PCASG funds to support services for almost 252,000 patients, who had over 1 million interactions with a health care provider. Other federal hurricane relief funds helped PCASG fund recipients pay staff, purchase equipment, and expand mental health services to help restore primary care. According to data from the Louisiana Department of Health and Hospitals, 11 recipients received HHS Social Services Block Grant (SSBG) supplemental funds designated by Louisiana for primary care, and 2 received SSBG supplemental funds designated by Louisiana specifically for mental health care. The funds designated for primary care were used to pay staff and purchase equipment, and the funds designated for mental health care were used to provide a range of services including crisis intervention and substance abuse prevention and treatment. Most of the PCASG fund recipients benefited from the Professional Workforce Supply Grant incentives. These recipients hired or retained 69 health care providers who received incentives totaling over $4 million to work in the greater New Orleans area. PCASG fund recipients face multiple challenges and have various plans for sustainability. Recipients face significant challenges in hiring and retaining staff, as well as in referring patients outside of their organizations, and these challenges have grown since Hurricane Katrina. For example, 20 of 23 recipients that responded to the 2008 GAO survey reported hiring health care providers was a great or moderate challenge, and over three-quarters of these 20 recipients reported that this challenge had grown since Hurricane Katrina. PCASG fund recipients also reported challenges in referring patients outside their organization for mental health, dental, and specialty care services. Although all PCASG fund recipients have completed or planned actions to increase their ability to be sustainable, recipients are concerned about what will happen when PCASG funds are no longer available. Officials of the Louisiana Public Health Institute, which administers the PCASG locally, expect that some recipients might have to close and others could be forced to scale back capacity by as much as 30 or 40 percent. They have suggested strategies to decrease what they estimate would be a $30 million gap in annual revenues when PCASG funds are no longer available. With the availability of PCASG funds scheduled to end in less than 10 months, preventing disruptions in the delivery of primary care services could depend on quickly identifying and implementing workable sustainability strategies.

section_title: Letter
paragraphs: I am pleased to be here today to discuss primary health care services in  the greater New Orleans area. My testimony is based primarily on our July  2009 report entitled Hurricane Katrina: Federal Grants Have Helped  Health Care Organizations Provide Primary Care, but Challenges  Remain. More than 4 years after Hurricane Katrina made landfall on  August 29, 2005, the greater New Orleans area continues to face challenges  in restoring health care services disrupted by the storm. Before the  hurricane, most health care for the low-income and uninsured population  in the area was provided in emergency rooms and outpatient clinics at  Charity and University hospitals, which were part of the statewide  Louisiana State University (LSU) public hospital system. About half of the  hospitals’ patients were uninsured, and about one-third were covered by  Medicaid. Following the hurricane and the subsequent flooding, the  hospitals and clinics closed because of the significant damage they had  sustained. In November 2006, LSU reopened University Hospital under its  new, temporary name, Interim LSU Public Hospital, which is operating at a  lower capacity than Charity’s and University’s pre-Katrina capacity;  Charity Hospital remains closed. While health care provider organizations  in the area were able to reopen some health care clinics, gaps in the  availability of primary care services in the greater New Orleans area  remained.
To help address the continuing health care needs of low-income area  residents, the Department of Health and Human Services (HHS) awarded  the $100 million Primary Care Access and Stabilization Grant (PCASG) to  the Louisiana Department of Health and Hospitals (LDHH) in July 2007.
The grant is administered at the federal level by HHS’s Centers for  Medicare & Medicaid Services (CMS) and at the local level by the  Louisiana Public Health Institute (LPHI), the local partner of LDHH. The  PCASG is intended to restore and expand access to primary care services,  including mental health care services and dental care services, without  regard to a patient’s ability to pay, and to decrease costly reliance on  emergency room use for primary care services for patients who are  uninsured, underinsured, or covered by Medicaid. In addition to primary  care services, PCASG fund recipients can use grant funds to provide  specialty care, such as cardiology and podiatry services, and ancillary  services, including supporting services such as translation, transportation,  and outreach. LDHH provided funds to 25 outpatient provider  organizations, which we refer to as PCASG fund recipients. As of March  20, 2008, the recipients were operating 75 sites that were eligible to use  PCASG funds. For an organization to be eligible for PCASG funding, it  must have been a public or private nonprofit organization serving patients  in the greater New Orleans area at the time that Louisiana’s grant proposal  was submitted. It must also have had the intent to be sustainable, that is,  able to continue providing primary care after PCASG funds are no longer  available. The PCASG was given only to the state of Louisiana. PCASG  funds were made available to Louisiana for a 3-year period, from July 23,  2007, through September 30, 2010. As of June 22, 2009, PCASG fund  recipients had received more than $80 million in PCASG funds.
Since the disruption to the health care system caused by the hurricane,  several HHS agencies have awarded other grants that facilitate access to  primary care. However, like the PCASG funding, much of the funding is  temporary. HHS’s Administration for Children and Families provided  Social Services Block Grant (SSBG) supplemental funds to Louisiana,  which subsequently dedicated a portion specifically for health care  services, including mental health care. The Secretary of HHS awarded  Professional Workforce Supply Grant funds to reduce shortages in the  professional health care workforce. The funds were distributed as  financial incentives to eligible health care providers; eligibility  requirements included agreeing to serve Medicare, Medicaid, and  uninsured patients. Grants from the Health Center Program of HHS’s  Health Resources and Services Administration (HRSA) were also available  during this time to certain organizations providing primary care services.  Under Section 330 of the Public Health Service Act, HRSA provides grants  to health centers nationwide to increase access to primary care, using a  competitive process to award grants. All health center grantees are  Federally Qualified Health Centers (FQHC), which enjoy certain federal  benefits such as enhanced Medicare and Medicaid payment rates.  However, not all FQHCs receive Health Center Program grants, and those  that do not are sometimes referred to as having an FQHC Look-Alike  designation. Four health center grantees served the greater New Orleans  area at the time HHS awarded the PCASG in July 2007.
My statement today is based primarily on our July 2009 report on the  PCASG, in which we examined (1) how PCASG fund recipients used the  PCASG funds to support the provision of primary care services in the  greater New Orleans area, (2) how PCASG fund recipients used and  benefited from other federal hurricane relief funds that support the  restoration of primary care services in the greater New Orleans area, and  (3) challenges the PCASG fund recipients continued to face in providing  primary care services, and recipients’ plans for sustaining services after  PCASG funds are no longer available. In addition, we updated selected  information from our 2009 PCASG report and relied on other related GAO  work.
To do the work for our July 2009 report on how federal grants helped  support primary care, we conducted site visits at 8 of the 25 PCASG fund  recipients during April 2008, during which we collected documents and  interviewed PCASG fund recipient, state, and local officials. Based in part  on information we gathered during the site visits, we developed a Web- based survey that focused on how recipients used PCASG funds, the  challenges they continued to face, and their plans for sustainability. We  administered the survey in October 2008. We received responses from 23  of the 25 recipients, a response rate of 92 percent. We also reviewed and  analyzed data from LDHH on expenditures related to the supplemental  SSBG and on awards made under CMS’s Professional Workforce Supply  Grant Program, reviewed the recipients’ applications for PCASG funding  and their plans for sustainability, and interviewed officials at LDHH and  PCASG fund recipients about how the recipients used PCASG and other  federal funds. We conducted the work for our July 2009 report from  February 2008 through June 2009. To update the work on the PCASG, we  interviewed state, LPHI, and PCASG fund recipient officials about  sustainability plans and reviewed and analyzed more recent data from  these officials about program funding and services. We conducted this  new work in October and November 2009 and shared the information we  obtained with HHS officials. In addition, we incorporated findings from  another July 2009 report, which examined barriers to mental health  services for children in the greater New Orleans area. We conducted the  original and updated work in accordance with all sections of GAO’s  Quality Assurance Framework that are relevant to our objectives. The  framework requires that we plan and perform the engagement to obtain  sufficient and appropriate evidence to meet our stated objectives and to  discuss any limitations in our work. We believe that the information and  data obtained, and the analysis conducted, provide a reasonable basis for  any findings and conclusions in this product. A detailed explanation of our  methodology for each of the 2009 reports is included in the respective  reports.
subsections: section_title: PCASG Fund Recipients Used PCASG Funds to Support Primary Care Services by Hiring Health Care Providers and Other Staff and Adding Services and Sites
paragraphs: PCASG fund recipients that responded to our October 2008 survey  reported that they used PCASG funds to hire or retain health care  providers and other staff, add primary care services, and open new sites.  (See table 1.) Recipients also said that the PCASG funds helped them  improve service delivery and access to care for the patients they served.  As of September 20, 2009, PCASG recipients reported to LPHI that they  had used PCASG funds—in conjunction with other funds, such as other  federal grants and Medicaid reimbursement—to support services provided  to almost 252,000 patients. These patients had over 1 million encounters  with a health care provider, two-thirds of which were for medical and  dental care and one-third of which were for mental health care. A small  number of encounters were for specialty care. The patients served by the  PCASG fund recipients were typically uninsured or enrolled in Medicaid.  We reported in July 2009 that for the first several months during which  PCASG funds were available, at more than half of the PCASG fund  recipients, at least half—and at times over 70 percent—of the patient  population was uninsured.
Of the 20 recipients that reported in our October 2008 survey that they  used PCASG funds to hire health care providers, half hired both medical  and mental health providers. (See fig. 1.) One recipient reported that by  hiring one psychiatrist, it could significantly increase clients’ access to  services by cutting down a clinic’s waiting list and by providing clients  with a “same-day” psychiatric consultation or evaluation. Another  recipient reported that it hired 23 medical care providers, some of whom  were staffed at its new sites. Some recipients reported that hiring  additional providers enabled them to expand the hours some of their sites  were open.
Of the 23 recipients that responded to our survey, 17 reported they used  PCASG funds to retain health care providers, and 15 of these reported that  they also used grant funds to retain other staff. For example, one recipient  reported that PCASG funds were used to stabilize positions that were  previously supported by disaster relief funds and donated services.
Nineteen of the 23 PCASG fund recipients that responded to our survey  reported using PCASG funds to add or expand medical, mental health, or  dental care services, and more than half of these added or expanded more  than one type of service. Specifically, 11 added or expanded medical care,  15 added or expanded mental health care, and 4 added or expanded dental  care services. In addition, PCASG fund recipients also reported using grant  funds to add or expand specialty care or ancillary services. One recipient  reported that it used PCASG funds to create a television commercial  announcing that a clinic was open and that psychiatric services were  available there, including free care for those who qualified financially.
Almost all of the PCASG fund recipients that responded to our survey  reported they used PCASG funds for their physical space. Ten recipients  that responded to our survey reported using grant funds to renovate  existing sites, such as expanding a waiting room, adding a registration  window, and adding patient restrooms, to accommodate more patients.  Officials from one PCASG fund recipient reported that relocating to a  larger site allowed providers to have additional examination rooms.
PCASG fund recipients that responded to our survey reported that certain  program requirements—such as developing a network of local specialists  and hospitals for patient referrals and establishing a quality assurance and  improvement program that includes clinical guidelines or evidence-based  standards of care—have had a positive effect on their delivery of primary  care services. In addition, they reported that the PCASG funds helped  them improve access to health care services for residents of the greater  New Orleans area. For example, one PCASG fund recipient reported that  the PCASG funds have helped it to expand services beyond residents in  shelter and housing programs to include community residents who were  not homeless but previously lacked access to health care services.  Representatives of other PCASG fund recipients have reported that their  organization improved access to care by expanding services in medically  underserved neighborhoods or to people who were uninsured or  underinsured. Representatives of local organizations also told us the  PCASG provided an opportunity to rebuild the health care system and shift  the provision of primary care from hospitals to community-based primary  care clinics.
section_title: Other Federal Hurricane Relief Funds Helped PCASG Fund Recipients to Pay Staff, Purchase Equipment, and Expand Mental Health Services to Help Restore Primary Care
paragraphs: PCASG fund recipients also used other federal hurricane relief funds to  help support the restoration of primary care services. According to LDHH  data, as of August 2008, 11 PCASG fund recipients expended $12.9 million  of the SSBG supplemental funds that were awarded to Louisiana and that  the state designated for primary care. They used these funds to pay for  staff salaries, purchase medical equipment, and support operations. For  example, one recipient used SSBG supplemental funds to hire new  medical and support staff and, as a result, expanded its services for  mammography, cardiology, and mental health. The two PCASG fund  recipients that received a total of almost $12 million in SSBG supplemental  funds designated for mental health care used those funds to provide crisis  intervention, substance abuse, and other mental health services, mostly  through contracts to other organizations and providers. The majority of  funds were expended on the categories LDHH identified as “substance  abuse treatment and prevention services,” “immediate intervention and  crisis response services,” and “behavioral health services for children and  adolescents.”
As of August 2008, most of the 25 PCASG fund recipients had retained or  hired a health care provider who had received a Professional Workforce  Supply Grant incentive payment to continue or begin working in the  greater New Orleans area. Among the health care providers working for  PCASG fund recipients, 69 received incentives that totaled $4.5 million.  The number of those health care providers who were employed by  individual PCASG fund recipients ranged from 1 or 2 at 7 recipient  organizations to 10 at 2 recipient organizations. Three-quarters of  recipients of incentive payments were existing employees who were  retained, while one-quarter were newly hired.
section_title: PCASG Fund Recipients Face Multiple Challenges and Have Various Plans for Sustainability
paragraphs: PCASG fund recipients face significant challenges in hiring and retaining  staff, as well as in referring patients outside of their organizations, and  these challenges have grown since Hurricane Katrina. Recipients are  taking actions to address the challenge of sustainability, but are concerned  about what will happen when PCASG funds are no longer available.
subsections: section_title: PCASG Fund Recipients Face Significant Staffing and Referral Challenges, and These Challenges Have Grown Since Hurricane Katrina
paragraphs: Although most of the 23 PCASG fund recipients that responded to our  October 2008 survey hired or retained staff with grant funds, most have  continued to face significant challenges in hiring and retaining staff.  Twenty of the 23 recipients reported the hiring of health care providers to  be either a great or moderate challenge. Among those, over three-quarters  responded that this challenge had grown since Hurricane Katrina. For  example, in discussing challenges, officials from one recipient  organization told us that after Hurricane Katrina they had greater difficulty  hiring licensed nurses than before the hurricane and that most nurses  were being recruited by hospitals, where the pay was higher. Moreover,  officials we interviewed from several recipient organizations said that the  problems with housing, schools, and overall community infrastructure that  developed after Hurricane Katrina made it difficult to attract health care  providers and other staff. In addition, 16 of the 23 recipients reported that  retaining health care providers was a great or moderate challenge. Among  those, about three-quarters also reported that this challenge had grown  since Hurricane Katrina.
An additional indication of the limited availability of primary care  providers in the area is HRSA’s designation of much of the greater New  Orleans area as health professional shortage areas (HPSA) for primary  care, mental health care, and dental care. Specifically, HRSA designated  all of Orleans, Plaquemines, and St. Bernard parishes, and much of  Jefferson Parish, as HPSAs for primary care. While some portions of the  greater New Orleans area had this HPSA designation before Hurricane  Katrina, additional portions of the area received that designation after the  hurricane. Similarly, HRSA designated all four parishes of the greater New  Orleans area as HPSAs for mental health in late 2005 and early 2006;  before Hurricane Katrina, none of the four parishes had this designation  for mental health. In addition, HRSA has designated all of Orleans, St.  Bernard, and Plaquemines parishes and part of Jefferson Parish as HPSAs  for dental care; before Katrina, only parts of Orleans and Jefferson  parishes had this designation.
The PCASG fund recipients that primarily provide mental health services  in particular faced challenges both in hiring and in retaining providers. Six  of the seven that responded to our October 2008 survey reported that both  hiring and retaining providers were either a great or moderate challenge.  Officials we interviewed from one recipient told us that while the Greater  New Orleans Service Corps, which was funded through the Professional  Workforce Supply Grant, had been helpful for recruiting and retaining  physicians, it had not helped fill the need for social workers. Furthermore,  officials we interviewed from two recipients told us that some staff had  experienced depression and trauma themselves and found it difficult to  work in mental health settings. Beyond challenges in hiring and retaining  their own providers and other staff, PCASG fund recipients that responded  to our survey reported significant challenges in referring their patients to  other organizations for mental health, dental, and specialty care services.
We also reported on a lack of mental health providers in our July 2009  report that examined barriers to mental health services for children in the  greater New Orleans area. Specifically, 15 of the 18 organizations we  interviewed for that work identified a lack of mental health providers— including challenges recruiting and retaining child psychiatrists,  psychologists, and nurses—as a barrier to providing mental health services  for children. In addition, we reported that HRSA’s Area Resource File  (ARF)—a county-based health resources database that contains data from  many sources including the U.S. Census Bureau and the American Medical  Association—indicated that the greater New Orleans area has experienced  more of a decrease in mental health providers than some other parts of the  country. For example, we found that ARF data documented a 21 percent  decrease in the number of psychiatrists in the greater New Orleans area  from 2004 to 2006, during which time there was a 1 percent decrease in  Wayne County, Michigan (which includes Detroit and which had pre- Katrina poverty and demographic characteristics similar to those of the  greater New Orleans area) and a 3 percent increase in counties  nationwide.
section_title: PCASG Fund Recipients Are Taking Actions to Address the Challenge of Sustainability, but Are Concerned About What Will Happen When PCASG Funds Are No Longer Available
paragraphs: In our July 2009 report on the PCASG, we found that an additional  challenge that the PCASG fund recipients face is to be sustainable after  PCASG funds are no longer available in September 2010. All 23 recipients  that responded to our October 2008 survey reported that they had taken or  planned to take at least one type of action to increase their ability to be  sustainable—that is, to be able to serve patients regardless of the patients’  ability to pay after PCASG funds are no longer available. For example, all  responding recipients reported that they had taken action—such as  screening patients for eligibility—to facilitate their ability to receive  reimbursement for services they provided to Medicaid or LaCHIP  beneficiaries. Furthermore, 16 recipients that responded to our October  2008 survey reported that they were billing private insurance, with an  additional 5 recipients reporting they planned to do so. However,  obtaining reimbursement for all patients who are insured may not be  sufficient to ensure a recipient’s sustainability, because at about half of the  PCASG fund recipients, over 50 percent of the patients were uninsured.
Many PCASG fund recipients reported that they intended to use Health  Center Program funding or FQHC Look-Alike designation—which allows  for enhanced Medicare and Medicaid payment rates—as one of their  sustainability strategies. Four recipients were participating in the Health  Center Program at the time they received the initial disbursement of  PCASG funds. One of these recipients had received a Health Center New  Access Point grant to open an additional site after Hurricane Katrina and  had also received an Expanded Medical Capacity grant to increase  service capacity, which it used in part to hire additional staff and buy  equipment. Another of these recipients received a New Access Point grant  to open an additional site after receiving PCASG funds. Beyond these four  recipients, one additional recipient received an FQHC Look-Alike  designation in July 2008.
HRSA made additional grants from appropriations made available by   the American Recovery and Reinvestment Act of 2009, awarding five  PCASG fund recipients with additional Health Center Program grants  totaling $7.4 million as of October 19, 2009. Specifically, three PCASG  fund recipients were awarded New Access Point grants totaling   $3.9 million, five received Capital Improvement Program grants totaling  more than $2.4 million, and five received Increased Demand for Services  grants totaling nearly $1.1 million.
Of the remaining 18 recipients that responded to our survey, 6 said they  planned to apply for both a Health Center Program grant and an FQHC  Look-Alike designation. In addition, one planned to apply for a grant only  and another planned to apply for an FQHC Look-Alike designation only.  Although many recipients indicated that they intended to use Health  Center Program funding as a sustainability strategy, it is unlikely that they  would all be successful in obtaining a grant. For example, in fiscal year  2008 only about 16 percent of all applications for New Access Point grants  resulted in grant awards.
About three-quarters of PCASG fund recipients reported that as one of  their sustainability strategies they had applied or planned to apply for  additional federal funding, such as Ryan White HIV/AIDS Program grants,  or for state funding. In addition, a few reported that they had applied or  planned to apply for private grants, such as grants from foundations.
In our fall 2009 interviews, LPHI and PCASG recipient officials told us that  there is uncertainty and concern among the PCASG fund recipients as the  time approaches when PCASG funding will no longer be available. LPHI  officials told us that they expect that some PCASG fund recipients might  have to close, and others could be forced to scale back their current  capacity by as much as 30 or 40 percent. For example, one PCASG fund  recipient official we spoke with in November 2009 told us that the  organization’s mobile medical units may not be sustainable without  PCASG funding; services provided by mobile units are not eligible for  Medicaid funding without a referral and collecting cash from patients  could make the units targets for crime. LPHI officials said they expect that  the loss of PCASG funds would most affect PCASG fund recipients that  serve the largest number of uninsured patients.
To help PCASG fund recipients achieve sustainability, the LPHI developed  a sustainability strategy guide in April 2009. This guide suggests actions  that the recipients could take to become sustainable entities, such as  maximizing revenues by improving their ability to screen patients for  eligibility for Medicaid and other third party payers, enroll eligible  patients, electronically bill the insurers, and collect payment from  insurers.
LPHI and a PCASG fund recipient have identified additional potential  approaches for securing revenues to decrease what LPHI estimated would  be a $30 million gap in the PCASG fund recipients’ annual revenues when  PCASG funds are no longer available. The LPHI sustainability strategy  guide proposed that expanding Medicaid eligibility through a proposed  Medicaid demonstration project that HHS is reviewing could result in a  decrease in the number of uninsured people; these are the patients for  whom PCASG fund recipients are most dependent on federal subsidies.  The LPHI guide also suggested that it could be helpful if Louisiana  received greater flexibility to use Medicaid disproportionate share dollars  for outpatient primary care not provided by hospitals. In addition, a  PCASG fund recipient official told us in November 2009 that a no-cost  extension for PCASG funds might help some PCASG fund recipients if  they are able to stretch their PCASG dollars beyond September 30, 2010.
Although PCASG fund recipients have completed or planned actions to  increase their ability to be sustainable and have received guidance from  LPHI, it is unclear which recipients’ sustainability strategies will be  successful and how many patients recipients will be able to continue to  serve. With the availability of PCASG funds scheduled to end in less than  10 months, preventing disruption in the delivery of primary care services  could depend on quickly identifying and implementing workable  sustainability strategies.
Mr. Chairman, this completes my prepared remarks. I would be happy to  respond to any questions you or other members of the committee may  have at this time.
section_title: Contacts and Acknowledgments
paragraphs: For further information about this statement, please contact Cynthia A.  Bascetta at (202) 512-7114 or bascettac@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this statement. Key contributors to this statement were Helene  F. Toiv, Assistant Director; Carolyn Feis Korman; Deitra Lee; Coy J.  Nesbitt; Roseanne Price; and Jennifer Whitworth.
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