Report on Louisiana Healthcare Delivery and Financing System* *connectedthinking Contents 01 Executive summary 03 Introduction 05 Key findings and recommendations 16 Section I: Vision and mission of the Louisiana healthcare system 18 Vision for the Louisiana healthcare system 18 Mission of the Louisiana healthcare system 20 Section II: Measures and optimizing the healthcare system for the future 21 Research 21 Key findings and recommendations 23 Background 26 The population’s most prevalent illnesses and conditions 27 Moving towards optimizing the performance of Louisiana’s system 28 IOM Aim: Safe 29 IOM Aim: Effective 30 IOM Aim: Patient-centered 31 IOM Aim: Timely 31 IOM Aim: Efficient 33 IOM Aim: Equitable 34 Development of integrated healthcare systems: how Louisiana’s healthcare could improve 34 Integrated healthcare systems take a holistic approach to the patient and the population 35 Ways in which integrated health systems improve quality and cost 37 Health plans and payer impact on the quality of healthcare 39 The pre and post-hurricanes healthcare system in Louisiana 41 A reconfigured system for Louisiana 45 Bed need analysis methodology 48 Region 1 (New Orleans) 54 Region 2 (Baton Rouge) 55 Region 3 (Houma-Thibodaux) 56 Region 4 (Lafayette) 57 Region 5 (Lake Charles) 58 Region 6 (Alexandria) 59 Region 7 (Shreveport) 60 Region 8 (Monroe) 61 Region 9 (Covington-Slidell) 62 Trauma centers 63 Hospital outpatient and emergency departments 64 Ambulatory care 65 Long-term acute care 66 Mental health services 67 Investing to meet IOM goals—programs and process 68 Investing to meet IOM goals—operations and capital 69 The current public system and options for reconfiguration 73 Appendices for measures and optimizing the healthcare system for the future 90 Section III: Workforce and medical education 91 Research 91 Key findings and recommendations 94 Workforce 94 Workforce planning 95 Medical workforce issues 99 Allied health workforce issues 102 Nursing 104 Recruitment and retention 108 Effects of salary on recruitment and retention 108 The future state of the workforce 118 Medical education 118 Introduction 121 Medical school characteristics 121 Debt load among graduating Louisiana medical students 122 Funding of graduate medical education 124 Faculty and resident levels 125 The flow of residents 126 Current models for medical education in Louisiana 127 Lessons for the future from benchmark medical programs 129 Future of medical education in Louisiana post hurricanes 137 Appendices for workforce and medical education 150 Section IV: Public and private technology infrastructure 151 Research 151 Key findings and recommendations 152 Chronology of health information technology 154 Current state of health information technology in Louisiana 158 Creating the infrastructure for health information exchange in Louisiana by 2015 159 Governance 160 Financing 160 Technical infrastructure 160 Phases of development 165 Appendices for public and private technology infrastructure 170 Section V: Emergency preparedness and disaster planning 171 Key findings and recommendations 172 Nature of a disaster 175 Disaster planning 185 Preparing the Louisiana health system for the future 197 Conclusion 200 Section VI: Financing 201 Key findings and recommendations 204 Framework to reward improved outcomes and restructure delivery system financing 204 Summary 205 Pre-hurricanes financing of healthcare 207 Medicaid 207 Medicare 208 Uninsured 209 Commercial 210 Opportunity to emphasize and reward improved quality outcomes 212 Capital investment requirements and financing options 213 The economic value proposition and delivery system financing options 216 Summary of annual investment and estimated value proposition 220 Interviewees 222 Glossary This Report is intended for the use and benefit of the Louisiana Recovery Authority Support Foundation only and not intended for reliance by any other Party. Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this review is to provide candid and critical comments that will assist in making this report as sound as possible. The review comments and draft manuscripts remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this report: Dr. Christine Cassel President, American Board of Internal Medicine Dr. Jordan Cohen President, Association of American Medical Colleges Robert Dickler Senior Vice President, Association of American Medical Colleges Jeanne Lambrew, Ph.D. Associate Professor of Health Policy Analysis, George Washington University Margaret O’Kane President, National Committee for Quality Assurance Diane Rowland, Sc.D. Executive Vice President, Kaiser Family Foundation & Executive Director of the Kaiser Commission on Medicaid and the Uninsured Myrl Weinberg, CAE President, National Health Council Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. All review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authors of this report. Executive summary Report on Louisiana Healthcare Delivery and Financing System* PricewaterhouseCoopers LLP was retained by the Louisiana Recovery Authority Support Foundation (the Foundation, a foundation created to serve in support of the Louisiana Recovery Authority (LRA)). The Foundation was created to provide experts needed by Louisiana Recovery Authority committees. To date, the Foundation has provided experts in community redevelopment, regional planning, repopulation research, public relations and healthcare. No public funds were spent on the production of this report. The Foundation raised private funds to pay for PricewaterhouseCoopers’ work on this document. The LRA Support Foundation and its Board of Directors were not involved in gathering of data, interviews or production of this report. PricewaterhouseCoopers produced the findings of this report independently and without any involvement from the LRA Support Foundation or its board members. This report is owned by the Foundation, which reserves all rights associated with its production. The board members of the Foundation are as follows: Mr. John Laborde—Chairman, New Orleans Ms. Brenda Birkett—Lake Charles Mr. Ron Forman—New Orleans* Mr. King Milling—New Orleans Mr. Sean Reilly—Baton Rouge Mr. David Voelker –New Orleans * Mr. Forman took a leave of absence to run for Mayor of New Orleans The LRA, established this past fall, was created to identify and prioritize the short and long-term needs of the post-hurricanes affected areas, and to seek out and value local input as it plans and implements the recovery efforts. The Public Health & Healthcare (PHH) Task Force, as one of thirteen LRA task forces, is focusing specifically on issues related to the short-term delivery of healthcare, the development of alternatives for rebuilding the state’s healthcare infrastructure, and the planning for future emergencies that require coordination among the state’s healthcare facilities and workforce. The PHH Task Force divided its focus into four Priority Areas. These Priority Areas are as follows: • Redesigning a Sustainable Healthcare System in Affected Areas, • Healthcare Workforce & Medical Education, • Disaster Planning & Emergency Preparedness, and • Short-Term Recovery Focusing on three of the PHH Task Force’s Priority Areas, referred to as the Long-Term Priority Areas, the Foundation requested PricewaterhouseCoopers to assist in developing recommendations—widely viewed by local, regional and national experts—to the LRA that can significantly improve the healthcare delivery system in Louisiana. Specifically, PricewaterhouseCoopers was engaged to perform the advisory services (the Services) as delineated in the engagement letter of the agreement dated January 26, 2006, and such Services are subject to the terms and conditions included therein. The objective of the engagement was to provide project management, data collection and analyses related to the development of recommendations for the recovery and rebuilding of the Louisiana healthcare system. These services were focused on the following three priority areas: • Healthcare System—to define the vision and mission for the healthcare system of the state of Louisiana and to develop recommendations for a sustainable long-term healthcare system. Report on Louisiana Healthcare Delivery and Financing System* 1 • Healthcare Professionals & Medical Education—to determine the optimal array of qualified healthcare professionals in the state to support the mission of the healthcare system, and develop a strategy for immediate recovery of displaced workers and long-term retention of an effective workforce aligned with changing demand. • Emergency Preparedness & Disaster Planning—to develop a time-sensitive illness response system linking homeland security initiatives with healthcare operational standards and trauma care requirements, using a consistent disaster planning framework. The Services were performed in accordance with Standards for Consulting Services established by the American Institute of Certified Public Accountants (AICPA). The procedures we performed did not constitute an examination or review in accordance with generally accepted auditing standards or attestation standards. Accordingly, we provide