New Orleans Two Years Later
New Orleans Two Years Later
Eyecare practices are rebuilding and rebounding.
BY RENÉ LUTHE, SENIOR ASSOCIATE EDITOR
When the American Academy of Ophthalmology (AAO) convenes its annual meeting in New Orleans in November, AAO members will see that the city's hotels and restaurants are open and operating normally. However, that will not be the whole picture. There are still many stories of struggle, including how fellow ophthalmologists have been affected by the worst natural disaster ever to strike the United States. This article will examine the stories of ophthalmologists in the region who took the time to share their experiences with Ophthalmology Management, as well as detail how they are bringing their practices back under formidable challenges.
In the Aftermath
The physicians interviewed for this article report that immediately after the storm, they faced evacuation, finding new living accommodations, commuting long distances to alternate practices and rebuilding water- and wind-damaged offices. Phone service was nonexistent and even cell phone service was unreliable in the wake of the storm, in some areas for weeks, making it difficult to contact colleagues and staff about the status of a practice.
In New Orleans, Donald R. Bergsma, M.D., director of the Louisiana State University (LSU) Eye Center and chair of the ophthalmology department, LSU School of Medicine, reports that if your practice was above sea level, you only had to worry about your home and family. If it was below sea level, you faced a severely damaged site. He evacuated to Baton Rouge, La., staying in the guest home of one of his faculty members. He practiced at the Earl K. Long Hospital there, where LSU has a residency program. After approximately 6 weeks, his family was able to return to their home, but then Dr. Bergsma had to commute 90 miles per day to Baton Rouge to see patients there.
Jobie F. Crear, M.D., of Washington Avenue Medical Center in New Orleans, had to evacuate his home with his family due to floodwaters. They spent a week sleeping on the floor in the home of one of his students before purchasing another home 100 miles from New Orleans and living there for 1 year. One of his practices was underwater and another was severely damaged by the storm. His wife, a dentist, lost both her practices. While trying to rebuild, they established a practice in Baton Rouge and have been dividing their time between the two cities since.
In nearby Jefferson Parish, Ronald A. Landry, M.D., also had to evacuate his home. He returned 6 days later — by boat — and had to wade in. His family was only able to return to that house 2 months ago.
"The area I'm in is pretty affluent and yet it's very slow coming back, so it's not just the underprivileged people who have been hurt," he says.
Dr. Landry's Metairie-based practice, in a suburb of New Orleans, had sustained some flooding and wind damage. He and his staff began a round-the-clock, 7-day-per-week effort to reopen the practice, but despite the relatively small amount of damage, it took 5 weeks because there was no power or phones much of the time. His practice's electrical system had been damaged as a result of being without power for so long.
Stephen F. Brint, M.D., in private practice and associate clinical professor of ophthalmology at Tulane University, was fortunate enough not to be in New Orleans when Katrina struck, but when he did return a month later, he found that much of the equipment in his two offices had been damaged — not by winds or floodwaters, but by the lack of electricity that left it vulnerable to the high temperatures and humidity. "I lost three of the lasers I use for LASIK," he says.
His efforts to reopen also suffered from the unreliable phone service that affected New Orleans for a long period after the storm. One of his employees was able to get into the practice and retrieve a computer and to eventually get the phone line transferred to her home.
"We weren't really able initially to set up any new appointments, because we didn't know what the future held," Dr. Brint says. "But at least we could make contact with our patients, call the ones who had been scheduled for surgery and let them know that we would stay in touch." That situation lasted for several weeks until he was able to open his anterior segment office approximately half-time, and eventually full-time, as well as open his second office. That took about 2 months, he reports. Dr. Brint also practiced for a short time in California, but he found the commute too arduous and affiliated with another New Orleans physician in late 2006.
In the Gulf Coast region, George M. Thurber, M.D., returned to find his home leveled. "We couldn't find our refrigerator, our stove; my neighborhood looked like the surface of the moon," he says. One of his offices was destroyed as well, though his main office, in Biloxi, Miss., was relatively unscathed. "So literally a week after the storm, I opened up," Dr. Thurber says. "And you would not believe the number of people who were pouring in."
|The Fate of the Teaching Hospitals|
|"The most devastating thing to us after the storm was that four of our major teaching institutions were ruined by the flood waters: Charity Hospital, the VA [Veterans Administration] Hospital, University Hospital and the LSU [Louisiana State University] Eye Center," says Dr. Bergsma.|
At the Eye Center, the first floor was flooded with more than a foot of water that severely damaged the electrical systems. Faculty was finally able to return to the Eye Center site in March 2006.
Dr. Bergsma estimates that the Eye Center is "about 80% put back together" now. For instance, LSU and FEMA came to an agreement only last month to renovate five stories in the Eye Center, including installing more safety features, bringing the generators up to the second floor and adding new stairwells to improve patient flow.
University Hospital has reopened, but Dr. Bergsma describes the VA Hospital as "limping along. They send their surgery to Tulane," he says. "They do have a clinic in Baton Rouge, which we staff, and they do see outpatients, but they have no real hospital program, so that can show you how long this recovery takes."
However, Dr. Bergsma reports that the Eye Center was able to save its research programs, partly by moving them to other sites. Though he lost half his clinical faculty, he managed to save the researchers. "One of our areas of strength is that we have a lot of ophthalmology research and a big neuroscience center that grew out of LSU," Dr. Bergsma says. "So there's a critical mass of interdisciplinary, interrelated research — people want to stay in a situation where they are productive."
Deciding Not to Return
Not all physicians returned to New Orleans. A January 2006 report from the Orleans Parish Medical Society claimed that only approximately one-third of the area's 4,000 doctors had returned. Charlene Baudier, executive director of both the Orleans Parish and Jefferson Parish medical societies, attributes the migrations to the harsh living conditions that persisted so long after Katrina. "Most docs who have not returned say that they have young children," she explains. "And probably the greatest problem was that schools were not open for several months — most were closed for 4 to 6 months after the storm — and so young families with school-aged children were where we took our greatest hit." Physicians who had concentrated their practice in Orleans, where the greatest flooding took place, usually found their patients had been uprooted, making it difficult to sustain a practice.
Dr. Crear believes that many physicians in their 50s and 60s took early retirement. "The thought of starting back up and putting out a negative capital outlay and then shutting the practice down, I think, was overwhelming," Dr. Crear says.
For those physicians who did take on the daunting challenge of returning and rebuilding, staffing was one of the most significant problems they faced in reopening their practices. Baudier confirms that hospitals and individual practices are still having difficulty finding qualified staff to hire due to the widespread dislocation of the population.
Dr. Brint reports losing two-thirds of his employees, a loss that played a large role in slowing the reopening of his practices. He says that most of his staff simply did not have homes to return to and so many relocated to cities such as Atlanta and Natchez, Miss.
"Trying to carry on with the reduced employee workload was pretty stressful for all of us," Dr. Brint says. The physician with whom he affiliated last year, Jeffrey Singer, M.D., had been fortunate enough to keep most of his staff.
Similarly, Dr. Crear reported that approximately 80% of his employees had not returned. "There is a tremendous shortage" of qualified healthcare personnel, he says. "And as a result, the costs [of running a practice] have gone up drastically." Couple that shortage with the fact that much of the pre-Katrina population has not returned to New Orleans, particularly the seniors toward whom ophthalmology is tilted, and the result is decreased revenues for many ophthalmic practices, Dr. Crear explains.
For LSU Eye Center, the staffing problem was particularly serious. Investigators are having difficulty attracting the type of qualified staff necessary for clinical research. "It's difficult to attract people to the city now," says Dr. Bergsma. "So rather than spend their time publishing and writing new grants, you've got a seasoned investigator doing bench work. It slows down efficiency."
Keeping the Practice Together
The practice leaders who were able to keep their staffs together after the storm tend to share some key strategies. At Dr. Landry's office, the staff already had a phone "disaster pyramid" set up prior to the storm. Even though phone service was down afterward, Dr. Landry and the practice manager could text-message staff evacuated to other states to inform them when the practice would reopen. Additionally, Dr. Landry's practice paid its staff for the time the office was closed. The doctors did not draw a salary themselves until almost 2 months after the storm, reports Cathy Perez, the practice's marketing director. They asked all their staff to return.
"That was something we had to think about, because the projection was that it would be a year or so before we were back to our normal volumes," says Dr. Landry. "But I said, 'Listen, if we're going to come back, we're going to come back with a full staff because you can't provide full service with a skeleton crew. If people come in, they want to get the care they would have gotten before. In retrospect, it was a great decision, because the need was there in Jefferson Parish."
Dr. Thurber also set up a cell phone network among his staff before Katrina hit. Additionally, he gave each member $400 in cash, because he knew that likely power failures from the hurricane would mean that no one would be able to utilize a credit card. He contacted his scattered staff a few days after the storm: Of 20 people, only one decided not to come back. He also paid them for the time the practice was closed. "We have always treated our staff very, very well," Dr. Thurber explains. "One of the things we tried to do was make sure there was no bump in their lives work-wise, because there were enough in their personal lives then. Some of them didn't have homes; some are to this day living in FEMA trailers. I am very proud of the fact that our staff members are so dedicated."
Coping With the Uninsured
Another significant problem in New Orleans since Katrina is the far larger number of uninsured patients. Dr. Crear points out that in the rebuilding effort, the population of New Orleans has become younger, more working-class and more migratory — and hence more likely to lack health insurance. Additionally, says Baudier, many of the people who have returned to the city have lost their jobs and thus their insurance coverage. Treating them is "a significant financial drain on the practice when the doctors are trying to rebuild themselves," she says, as the charity hospital system is still dramatically decreased in size. "Physicians in private practice are seeing patients mostly through hospital emergency room referrals, and there isn't a way, presently, for them to be paid for that." She believes that solving the problem of the uninsured would be a great help in making physicians feel more stable, as well as making exiled doctors feel better about returning and reopening their practices.
The Reimbursement Situation
One would expect reimbursements and billing to be snarled in the storm's aftermath, but physicians offer mixed reports. Soon after the storm, Dr. Brint says, the state government required physicians to treat patients without the benefit of precertification or knowing whether the patient really had insurance. "There was no way to really find out," he explains.
"Eventually, I think, we collected everything that was due, but it was a little troublesome at the time, to know that we might not be paid," Dr. Brint says.
Dr. Bergsma had a more unhappy experience. He reports that two of the five LSU Eye Center physicians who had practiced in Baton Rouge (the group worked there for approximately 10 months) have yet to receive any Medicare reimbursements "because you have to link up your Medicare numbers with your practice location," he explains. "This is absurd. [Some doctors are not being reimbursed] even though they are licensed to practice medicine in the state of Louisiana and had just moved to another city — and they are seeing their own patients. These are people from the area who had been blown out of New Orleans and would drive to see us — there's just that level of bureaucracy."
Dr. Landry said he found there were some small glitches with reimbursements just after Katrina, but nothing too serious.
For patients who were forced to relocate, the reimbursement problem could be serious. "A lot of patients had Medicare/Medicaid and when they crossed over into other states during the evacuation, getting into that kind of system again in another state could be cumbersome without interruption of service," Dr. Crear says. "The system was not really designed to handle people in a migratory state." This has resulted in episodic health care, which has been particularly disastrous for glaucoma patients.
"A lot of patients with advanced glaucoma have progressed to blindness in the interim between before the hurricane and the next time you see them," Dr. Crear says. "They had been seeing functionally before the storm and now it's just light perception or hand motion, and you realize it's the interruption of care that has done this."
Medical Practice Now
While patients in the harder-hit areas of New Orleans and the Gulf Coast may still find adequate medical care difficult to obtain, in other areas, the practice of medicine is close to pre-storm normal. Some surgeons report that refractive surgery is doing well. Dr. Thurber says that on his first day open, the first patients he saw were there to request LASIK.
"The patients were a husband and wife and the chart read, 'lost contacts and glasses in storm.' I thought, 'Well, I'm going to see a lot of this,'" Dr. Thurber says. When they told him what they really wanted, he thought it was "surreal. I said, 'But didn't you lose your house?' They answered, 'Yes, but we've been thinking about this for a long time and it's impossible to wear contacts or find glasses in this situation.'"
Similarly, Dr. Landry reports that business at the laser center of which he is a co-owner is picking up. He explains that initially, it was not as good as before the storm, because so many doctors were displaced. However, volume is now close to where it was pre-Katrina, "though we are one of the few laser centers around now," he says. His practice has sufficient patient volume to be open 6 days a week and employ six physicians.
Dr. Thurber believes the demand for refractive surgery is tied to a rather fatalistic attitude on the part of patients. "I think what happened is a lot of people have been waiting to do things — waiting to buy a boat, waiting to get LASIK — and when they saw everything destroyed, they said, 'What have I been waiting for? What am I doing saving my money if a storm is going to come along and wipe it out?'" he says. "I heard that from a number of people."
Dr. Brint, who had been doing 50% refractive/50% cataract surgery before the hurricane, took on more cataract procedures when he affiliated with his associate, who performs refractive surgery along a discount model. However, he intends to begin rebuilding his refractive practice. "I have not done any marketing since Katrina," Dr. Brint explains. "It's because of the problem of limited staff. Staff-wise, we were kind of inundated; the last thing we really needed was the phone ringing more."
The progression of the recovery indicates the time may be right to rebuild without having to resort to a discount model.
The physicians interviewed for this article were all glad they had remained in the Gulf Coast region to be part of the recovery and do not feel there is much they would have done differently. Still, all are aware that disaster could strike again with each hurricane season.
"I'm one of those praying we don't have another catastrophic event," Dr. Crear says. "Without further federal assistance, it would be overwhelming."
Drs. Brint and Thurber recommend having a backup practice in another location — one less vulnerable to catastrophic weather, if possible. Dr. Landry has applied for an out-of-state license.
"I certainly don't want to leave; I have a great practice here," he says. But "if this whole area got hit again and we could not come back that quickly, spending a whole year trying to find another place to practice would be difficult. So I've opened my eyes to other options. I think other people have done the same." OM
Ophthamology Management, Issue: August 2007