Status in the States: In Louisiana, Will Privatization Affect Efforts to Stop Cancer?

Evidence-Based Oncology, September/October 2013, Volume 19, Issue SP9

Just 3 governors made the Modern Healthcare Top 100 list for 2013, and Louisiana’s Bobby Jindal was among them.1 Jindal was included among the most influential weeks before the start of open enrollment under the Affordable Care Act, which featured elements he refused to roll out in his state. Louisiana would not have its own exchange to sign up enrollees, nor would it expand Medicaid.

That second decision has drawn loud and sustained criticism, given Louisiana’s history of poverty, health disparities, and cancer, much of it linked to oil and chemical interests along the Mississippi River. The corridor between Baton Rouge and New Orleans has long been called “cancer alley,” with many researchers noting the proximity of toxic emissions and cancer clusters among the poor.2

Jindal didn’t just opt out of Obamaacare. He crusaded against it, writing op-eds in national publications. As an alternative, he designed a path of privatization to deliver care to the poor, one that retains some elements of Louisiana’s famous two-tiered hospital system while shedding others. Before Jindal’s trusted health and hospitals secretary, Bruce Greenstein, resigned following a scandal, the two brought privatization and managed care elements to Medicaid as well.3

While privatization has both fans and critics—it has already resulted in the Louisiana State University hospital system laying off more than 1500 employees4— the bigger tumult came over Jindal’s denial of Medicaid to at least 214,000 Louisianans who might be eligible under the ACA.5 What outrages critics is Jindal’s perceived departure from his original plan, “Louisiana Health First,” unveiled in November 2008.6That blueprint, which came as Louisiana crawled back from Hurricane Katrina, called for expanding Medicaid to more caretakers of eligible children, or at least more additional low-income persons with chronic conditions.6 Offering the poor healthcare choices and providing preventive care at medical homes were seen not as dreams but possibilities, given Jindal’s expertise as a state and federal health official.

As Jindal built a modern academic medical center to replace New Orleans’ battered Charity Hospital, it seemed he would build a healthcare delivery system to match. The announcement came as 4 institutions—Ochsner Health System, and Tulane, Xavier and LSU— began to show the fruits of investing tobacco tax dollars on the LouisianaCancer Research Consortium (LCRC).7

Among its goals, the consortium seeks better screening and earlier diagnosis, to combat a phenomenon common among the poor: cancer mortality is worse than cancer incidence, because too often patients are not seen until their disease has progressed beyond a point where it can be treated effectively.

According to LCRC:

• In 2011, approximately 22,780 new cancer cases were diagnosed in Louisiana, excluding some skin cancers and carcinomas.

• About 8360 people living in Louisiana died from cancer during 2011.

• Although cancer mortality is improving, rates in Louisiana remain about 30% higher than the rest of the country.7

Beyond the political and media uproar, some amazing things are happening in cancer care in Louisiana. The growth of the New Orleans—based Ochsner Health System, its relationships with the state’s medical schools, and its decision to take over struggling institutions has allowed personalized medicine and cancer treatment pathways to take hold in places where change can

come slowly.

Ochsner, LSU, and Tulane collaborate through LCRC, and Ochsner is moving beyond treatment trials to preventive ones for breast and prostate cancer, 2 diseases that hit harder than normal here. So what’s the concern? While Jindal’s approach to upending Louisiana’s one-of-a-kind charity care system could spur even more collaboration, the failure to expand Medicaid means not everyone with cancer will get the same access, at least not now.

Toward a Public-Private Partnership

Over the past year, the big healthcare story in Louisiana has not involved cancer or the Affordable Care Act. It’s been about the transformation of Louisiana’s unique charity hospital system, which dates to 1736 and flourished under the populist governor Huey P. Long. Under Jindal, 9 of the state’s 10 charity institutions will convert from LSU management into public-private partnerships.

Five such partnerships are in place, with the remaining 4 set to begin in 2014. Proponents, led by Jindal, say the new system will reduce costs, improve care for patients, and offer better training for medical students. In an editorial published in July, Jindal claimed the partnerships were “on target” to save $125 million this year.8

Certainly, there is much in Louisiana’s old system to be desired; an Institute of Medicine study released in August found 6 of the 10 highest cost cities for Medicare were in Louisiana.9 (Among the cost drivers was a need to shed retirement obligations for the thousands of public employees in the hospital system; Jindal stated that the changes would wring out $82 million in annual savings.)8

For decades, critics of Louisiana’s charity hospital system asked whether the poor were best served with a system of healthcare segregation. The new arrangement does not fully dismantle the divide; the poor are still in separate facilities, but through partnerships these hospitals are now buttressed with private funding, management, and clinical expertise. Some critics predict private partners are biding their time and will absorb losses from the safety-net hospitals until Jindal leaves office, when Louisiana will expand Medicaid.

The partnerships are quite complex. Louisiana retains ownership of safety net hospital buildings, while the private partnership manages them and pay the state lease payments. In return, the private partners receive a share of Medicaid funds, starting with a guaranteed amount.

An interview with 2 top Ochsner physicians revealed the pluses and minuses of Jindal’s approach: Ochsner’s partnership with Leonard J. Chabert Hospital in Houma, Louisiana, gives that safety net hospital access to management and medical expertise it might otherwise lack. According to Ochsner Executive Vice President and Chief Medical Officer Joseph E. Bisordi, MD, FACP, Chabert is run just like any other hospital in Ochsner’s system. Thus, the partnerships can provide a different level of “access” for cancer patients who have coverage through Medicare or Medicaid. But therein lies the issue. For patients with incomes between Medicaid eligibility levels and 133% of the federal poverty line, “I am not sure we have an answer for those folks,” said John Cole, MD, who is Ochsner’s chair for hematology and oncology.

Steve Spires, health policy analyst for the Louisiana Budget Project, a nonpartisan research organization, said that the failure to expand Medicaid has longterm implications for the public-private partnerships, because state taxpayers will continue to experience the fallout of sick people overwhelming hospitals instead of seeking preventative care or catching cancer when it is treatable.

“The taxpayers will end up paying for this care,” Spires said. With cancer in particular, he said, “They will end up paying more than if we had paid for the preventive screening up front.”

Saving Lives Through Early Detection

The refusal to expand Medicaid frustrates those who have seen positive developments in healthcare over the past decade, including efforts to expand coverage for uninsured children and increase cancer screenings. A decade ago things seemed on the upswing, when Louisiana’s Legislature approved a tobacco tax to create the LCRC and seek a National Cancer Institute (NCI) designation within the state by promoting clinical trials.

Donna Williams, MPH, DrPH, has had a front-row seat for the decline in breast cancer mortality over the past decade.As director of Louisiana Cancer Control Programs for the LSU School of Public Health, she knows that early detection saves lives, because she has the data to prove it.

In 1995, the breast cancer screening rate in Louisiana for African American women was 59.1%, compared with a national average of 70.2%, putting Louisiana 48th among the states. LSU’s screening program launched in 2002, and data from the Centers for Disease Control and Prevention (CDC) revealed an immediate, steep drop in mortality among African American women, which later reversed somewhat after the massive population shifts following Hurricane Katrina.10,11

By 2010, Williams said, Louisiana ranked 22nd among the states for 2-year mammography screening, with a rate of 76.3%, slightly higher than the national average of 75.2%. Louisiana screened 78.3% of African American women in 2010, compared with a national rate of 78.9%.10 Breast cancer mortality rates for all women remain well below 2002 levels, according to CDC data. (Figure 1.)11 But the good news with breast and cervical cancer is not repeated in other cancers, Williams said. Many whospoke with Evidence-Based Oncology decried Louisiana’s low eligibility levels for Medicaid, which typically leave the uninsured with long waits for care once cancer is diagnosed, assuming it is diagnosed in time.

As Williams and others explained, federal law requires Medicaid coverage once breast or cervical cancer is diagnosed. “They have fast-track qualification,” Williams said. “It’s a 2-pager; the providers attach the medical documentation and it goes through in less than 2 weeks.” By contrast, “If you have prostate cancer, you’re out of luck,” she said. “We don’t have any programs specific to the other cancers.” Much will depend on where a patient lives; those who use New Orleans’ current replacement for the defunct Charity Hospital fare comparatively well to those in remote areas, Williams said. Those familiar with the experiences of Louisiana’s uninsured say long waits and travel times can be as deadly as the cancer itself.

“People die as a consequence of this. That is not an exaggeration,” said Moriba Karamoko, director of the Louisiana Consumer Healthcare Coalition. “You can say people have access to oncology lists, but if the waiting list is so long and people die waiting, what kind of access do people really have?”

A Complex History With Cancer

The Louisiana lifestyle, one that appreciates drinking, smoking, relaxing, and enjoying rich food (often fried), seems almost tailor-made to promote the kinds of cancers that are common in the state: lung, prostate, colorectal. Overlay an impoverished population, with demographics that tilt toward obesity, diabetes, and other risk factors associated with cancer, and it’s not a surprise that the state’s numbers are so high.

But another factor has been at work for decades: Louisiana’s relationship with industry. Because there are so many demographic and lifestyle factors in play, it has been impossible to prove that oil, gas, and chemical interests are responsible for even higher cancer incidence rates in certain areas of the state. The proximity of industry to cancer clusters in certain zip codes along the Mississippi, as well as western parishes like Cameron and Calcasieu, has long been noted.2 (Figure 2.)

Wilma Subra, a Louisiana native and winner of a MacArthur “genius” grant, gave up a career as a chemist for Gulf South Research 30 years ago. She founded a company to gather the science in support of residents who believed toxins from the plants near their homes were making them sick. She was able to document how the burning of toxic waste as fuel contributed to a spike in neuroblastomas in Amelia, Louisiana, and a judge ordered the facility closed.12 Subra told EBO that she has seen elevated levels of lung, brain, and organ cancers in areas where concentrations of polyvinyl chloride “are way over acceptable standards.” For years, she has worked with residents of Mossville, Louisiana, a community of mostly African Americans surrounded by chemical plants.

Subra says she’s no expert on healthcare policy, but the people she works with need more than they are getting. “We have a desperate need for medical care due to the toxic exposure,” she said. Young doctors rotate in and out, and they don’t always understand what they are seeing. She would like to see toxicologists on hand permanently; specialists are needed to treat the complex conditions that patients experience. But that requires money; either direct funding, or residents with Medicaid or health insurance.

“The community thinks there should be a free clinic,” Subra said. “But when you say ‘free’ industry goes beserk.”

Ochsner’s Growth, Into the Community

For decades, if you lived in Louisiana, or on the Gulf Coast of Mississippi or Alabama, and your doctor said, “Cancer,” the next word was, “Ochsner.”

The renowned clinic was founded by Alton Ochsner MD, who was among the first to document the link between cancer and cigarette smoking; despite being criticized for this pronouncement, he opened the first group medical practice in New Orleans in 1942.13

By fate of geography, Ochsner did not flood in 2005 during Hurricane Katrina and was able to stay open to serve residents after other hospitals went dark. Already a growing presence in Louisiana, it bought 3 hospitals in 2006,14 cementing a strong “system” that Bisordi said will be key to delivery cancer care going forward. “One of the advantages we have as a system that you may not have as a small community hospital, you don’t have the structure to be more efficient. We have the resources in our system,” he said.

In addition, Ochsner enjoys good collaborative relationships with LSU and Tulane medical schools, which have programs to boost minority participation in clinical trials, Bisordi said. “Some of the patient samples from clinics at Ochsner go for analysis at LSU,” he said. Today, Bisordi and Cole say their goal is to keep patients as close to home as possible for cancer care. Ochsner does more clinical trials by far than any other cancer center in Louisiana—Bisordi said about 6% of the 2600 new cancer patients who come through its system participate in one. Yet not all come to the main hospital on Jefferson Highway, right outside New Orleans. “Our thinking with the community hospitals is, ‘We don’t want the folks you can take care of.’ Cole said, “care is best delivered closest to home.”

Cole said the Ochsner system is developing consistent, evidence-based pathways for cancer care delivery, which will be shared at the community level with all hospitals and clinics. This is the expressed goal of the Affordable Care Act—to promote cost savings by developing measurable methods to provide care, not by withholding it. If cancer care delivery improves, but a group of Louisianans lacks the means to receive it, what happens?

The Rev. Fred Kammer SJ, a Jesuit priest, Yale-educated lawyer and the former head of Catholic Charities USA now based at Loyola University New Orleans, has written about Medicaid expansion. He said that the discussion of the issue remains elevated among opinion leaders in the state. “It’s a scandal,” he said.

As the exchanges opened, Spires, of the Louisiana Budget Project, agreed. “Once people see the inequity, that people below the 133% of the poverty line get nothing, it’s going to turn up the heat. It’s by no means an issue that’s going to go away.”References

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5. Medicaid expansion could help thousands of uninsured Louisiana residents: Editorial. The Times-Picayune. September 15, 2013. http://www.nola.com/opinions/index.ssf/2013/09/medicaid_expansion_could_help.html Accessed October, 7, 2013. (Note: This editorial quotes a state projection of Medicaid expansion at 214,000. Estimates varied; some were in excess of 500,000.)

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9. Catalanello R. 6 Louisiana cities among 10 most expensive for health care, report says. The Times-Picayune. August 3, 2013. http://www. nola.com/health/index.ssf/2013/08/six_louisiana_cities_lead_the.html. Accessed October 12, 2013.

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