Characteristics of Physician Relocation Following Hurricane Katrina

On Aug. 29, 2005 Hurricane Katrina made landfall along the U.S. Gulf Coast, leaving devastation in its wake. At least 1,808 deaths were attributed to the storm and subsequent flooding in Louisiana and Mississippi.¹ With total damage estimates exceeding US$100 billion, Hurricane Katrina emerged as the costliest natural disaster in United States history.² The scale of societal impact was likewise unprecedented, with more than 1.5 million people requiring evacuation.¹ Nearly two years after the storm, more than 200,000 residents remain displaced from their homes in the hardest-hit areas.³ 

In the aftermath of Hurricane Katrina, health care infrastructure and services sustained extensive disruption. Flooding in New Orleans forced a temporary shutdown of health care delivery in several parishes and led to the displacement of many local physicians from the region. By autumn 2005 nearly 6,000 physicians had been displaced from the Gulf region by Hurricane Katrina. Louisiana was most severely affected; among displaced physicians, 4,486 had formerly practiced in three New Orleans parishes (Orleans, Plaquemines and St. Bernard).⁴ According to Government Accountability Office statistics, only three of the nine hospitals in Orleans Parish had reopened by February 2006, with a total bed capacity reduced to approximately 20 percent of that before the storm.⁵ Among the state's largest public hospitals, Charity Hospital still remains closed, whereas University Hospital reopened in November 2006 with limited capacity.

A major aspect of health care system recovery relates to whether displaced physicians have returned, intend to return, or have permanently relocated their practice. Such decisions are likely to have a direct and profound effect on the long-term reconstitution of regional health care systems in the Gulf region; however, trends of physician displacement following Hurricane Katrina have not been reported in detail. The present study sought to investigate whether Hurricane Katrina has resulted in a significant loss of practicing physicians from disaster-stricken regions of the Gulf Coast. The authors examine the relocation patterns of local physicians following Hurricane Katrina, determine how the disaster affected their lives and practice, and identify lessons learned that can guide health care recovery efforts in future events.

A descriptive Internet-based survey was developed to investigate physician demographics and relocation patterns following Hurricane Katrina. The survey was jointly designed by the study team at the American Medical Association (AMA) Center for Public Health Preparedness and Disaster Response and the Tulane University School of Public Health & Tropical Medicine. A total of 46 questions addressed physician demographics, the magnitude of the storm's impact on personal and professional lives, and relocation status. Relocation was defined as residing at a different location from that before Hurricane Katrina. As part of the design process, the form and content of the survey were reviewed by board members of the Louisiana State Medical Society. Pilot testing was conducted with selected local physicians.

Survey participants were identified and selected from an AMA master file of all of the licensed physicians reporting addresses located within Federal Emergency Management Agency (FEMA)-designated disaster zones in Louisiana and Mississippi before August 2005. Corresponding e-mail addresses for potential survey participants were obtained from the 2006 Record of Physician Professional Activities. Physicians residing outside FEMA-designated disaster zones before the hurricane, those without a listed e-mail address, and those for whom the listed e-mail address was undeliverable were excluded from the study.

The survey was administered online by the AMA during spring 2006. Eligible participants were sent introductory letters via e-mail describing the purpose of the study with a link to the Internet-based survey. The survey was accessible during the period March 9, 2006–July 10, 2006. To enhance the response rate, announcements of the study and survey availability were made on local, state, and national medical society listservs and local medical society newsletters.

To verify that potential respondents met study criteria, entry of a pre-Katrina home ZIP code from participating physicians was required. ZIP code entries were automatically screened by the program so that the questionnaire could be accessed only when the ZIP code entered by a respondent matched a FEMA-designated disaster zone. For physicians requiring further assistance or clarification, a telephone number directing respondents to contact the study coordinators was provided on the website.

Descriptive data analysis was used to describe characteristics of respondents by calculating the proportions for categorical variables. Multivariate logistic regression was performed to identify the factors associated with physician nonreturn to original practice. For those remaining relocated out of state at the time of the survey, bivariate analysis using x² or Fisher exact test was performed to determine factors associated with plans to return to original practice. P < .05 was considered statistically significant. SAS version 9.1 (SAS Institute, Cary, NC) was used to perform all of the data analyses.

Based on reported ZIP codes, the AMA master file identified 5854 physicians (AMA members and nonmembers) who resided in the FEMA-designated disaster zones before August 2005. E-mail addresses were obtained for a total of 1266 (21.6 percent) of the identified physicians, of which 976 (77.0 percent) were active and 290 (23.0 percent) were returned as undeliverable. A total of 312 eligible responses were collected, yielding a response rate of 32.0 percent from contacted physicians who originally resided in the areas of interest, which represented 5.3 percent of the total affected physician population. A comparison of respondents versus nonrespondents revealed no statistically significant differences based on sex, specialty, board certification, AMA membership or other identifiable characteristics, apart from age (86.6 percent respondents >40 years old vs 79.6 percent nonrespondents >40 years old).

Among disaster zone respondents, 85.6 percent lived in Louisiana and 14.4 percent resided in Mississippi before Hurricane Katrina (Table 1). Approximately 80 percent of the physicians were men; a similar percentage reported being married, and 47.1 percent had children <18 years old living at home. Physicians ages 50 to 59 comprised the largest age group. More than half of all of the respondents had >20 years of medical experience. At least 67.3 percent had practiced in-state for >10 years, with 37.8 percent practicing in-state for >20 years. By specialty, 8.3 percent of all respondents designated themselves as family practice or general medicine practitioners.

By spring 2006, 75.6 percent (n = 236) of the respondents had returned to their original homes, whereas 24.4 percent (n = 76) reported a different place of residence (Table 2). Of those who remained displaced from their homes, 39.5 percent (n = 30) had temporarily relocated to another home within the same state, 19.7 percent (n = 15) had permanently relocated to another “... programs to address identified physician needs in the aftermath of the storm may give confidence to displaced physicians to return” home in the same state, 27.6 percent (n = 21) had temporarily relocated out of state, and 13.2 percent (n = 10) had permanently relocated out of state. At the time of the survey, 40.7 percent (n = 127) of physicians reported that the hospital with which they were primarily affiliated was closed as a result of the hurricane. Hospital closures disproportionately affected physicians who remained displaced (P = .058). For 19.6 percent (n = 61) of physicians who required new hospital privileges, the process ranged from “very easy” (29.5 percent), “easy” (34.4 percent), “difficult” (14.8 percent), to “very difficult” (19.7 percent). Physicians relocated out of state were significantly more likely than those who had returned home to characterize the process of acquiring new hospital privileges as “very difficult” (P = .017).

Reported damages to homes and workplaces are shown in Table 3. Virtually all of the physicians surveyed reported some level of damage to their homes, with 37.1 percent citing damages ranging from $10,000 to $50,000 and 39.7 percent reporting damages in excess of $50,000. At the workplace, most physicians sustained damages ranging from minimal to severe, with 45.2 percent citing business losses in excess of $50,000.

At the time of the survey, 24.4 percent (n = 76) of the respondents remained displaced. Of the physicians who had temporarily or permanently relocated either in-state or out of state, 90.8 percent reported continuing to practice medicine. For all of the respondents, factors associated with nonreturn to original employment included family or general medicine practice (odds ratio [OR] 0.42, 95 percent confidence interval [CI] 0.17–1.04; P= .059) and severe or complete damage to the workplace (OR 0.24, 95 percent CI 0.13–0.42; P < .001) (Table 4).

Among physicians remaining displaced from their home state (n = 31), 41.9 percent planned to return to their original practice location, 32.3 percent did not plan to return, and 25.8 percent remained uncertain regarding future plans. In this group, physicians who were female (P < .01), <40 years of age (P = .058), and had practiced <10 years in state (P = .032) were found to be significantly less likely to return to their original practice.

The priorities identified by respondents included financial assistance/grants to rebuild their practice (15.7 percent), financial assistance to rebuild their home (14.7 percent), information or assistance in obtaining staff for their practice (9.3 percent), assistance in finding employment (5.1 percent), information or assistance with obtaining a new medical license (4.8 percent), assistance with damaged medical records (3.8 percent), assistance communicating their current practice situation to their former patients (1.9 percent), and information about or assistance with obtaining medical liability insurance (1.3 percent).

Although a large number of Gulf Coast physicians have returned to the region, the deep impact of Hurricane Katrina on the local health care systems spawned by physical damage, physician relocation, and disruption of medical services is still being felt. Most displaced physicians were from Louisiana (85.6 percent), with a smaller segment from Mississippi (14.4 percent). Approximately 25 percent of all physician respondents indicated that they remained displaced at the time of the survey, >6 months after the hurricane. Nearly 10 percent remained out of state, with the preponderance of this group indicating that they were either unlikely to or uncertain about returning to their original practice. These findings of marked physician displacement and attrition in the hurricane-stricken Gulf Coast region are supported by other reports. As of July 2006 Blue Cross Blue Shield reported the number of physicians filing claims in the affected parishes in New Orleans as having been reduced to 48 percent of pre-Katrina levels, down from 3091 to 1502.6 In this study family and general medicine practice were found to be associated with non-return to original employment. These findings may support the contention that primary care services in disaster areas have been disproportionately affected. In Louisiana a State Board of Medical Examiners review found that the number of board-licensed primary care physicians in New Orleans fell by 28 percent, from 2,645 to 1,913 during the period August 2005–July 2006.⁷ 

Among physicians remaining displaced out of state, female physicians, younger practitioners and those who had practiced in-state for a few number of years appear less likely to return or express less certainty about returning to their original practice. The absence of key support sources, such as childcare services or extended family, in the disaster stricken areas may have contributed to a disinclination to return.

Physicians as a group sustained considerable personal and business-related financial losses. As expected, physicians whose homes were significantly damaged or destroyed were far more likely to be displaced at the time of the survey. Approximately 24 percent of those still relocated six months after the disaster reported complete destruction of their homes, and nearly 40 percent of this same group reported personal losses >$50,000. Interestingly, severe or complete damage to homes was not associated with non-return to original employment; however, physicians who had not returned were significantly more likely to report severe or complete damage to their workplace. Academic hospital centers were not spared. In January 2006 approximately 180 faculty were laid off from Tulane Medical School.⁸ In December 2006 Louisiana State University Health Science Center laid off 127 medical school faculty.⁹ As expected, hospital closures and downsizing had a major effect on local physicians.

This study has several important limitations. Attempts to trace displaced physicians in the aftermath of the storm presented a unique challenge. Given post-Katrina conditions, the study design team believed that an online survey would yield higher response rates than other data collection methods (eg., mail or telephone surveys). The total number of physician respondents represents a relatively small, although important cross-sectional sample of those affected by Hurricane Katrina (5.3 percent). Other physicians who may have been affected may not have been captured in the survey, such as those who lived outside but worked in designated FEMA disaster zones.

Although e-mail contact information was available for roughly only one in five physicians, no clear characteristics distinguished physicians who had provided this information to professional societies from those who had not. Reasons for nonparticipation may include expired records, disrupted Internet service, or insufficient time or interest on the part of those surveyed. Nonresponse bias is unlikely to affect the general conclusions of this study because an analysis of respondents and nonrespondents revealed only a modest difference in average age. Of note, this study probably underestimates overall relocation rates because physicians with undeliverable e-mail addresses and those who did not respond to the survey are more likely to have remained displaced. Estimates of reported damage to homes and workplaces are subjective and were not quantified. Physicians who were part of large practice groups or served on hospital staff would not necessarily be expected to reliably estimate workplace damages.

The principal importance of the findings is the cascade effect on health system recovery for every physician who opts not to return to his or her original practice. Patients requiring health care services are forced to seek care from a smaller pool of local providers and primary care practitioners, whereas other health care personnel originally employed by private practices that shut down must also relocate. Even the return of physicians to their original practice does not guarantee the complete restoration of medical services to pre-Katrina levels.

Reports of the personal and professional experiences of physicians affected by Hurricane Katrina offer some insights into the specific recovery needs of health care personnel. Many physicians reported obstacles such as strained living conditions, loss of housing, or difficulties with travel. Others cited numerous operational challenges including the relocation of former practice partners, shortage of cash to maintain operations, difficulty in retaining staff, and burden of treating increasing numbers of uninsured patients.

Several strategies that may facilitate the return of displaced physicians following future natural disasters are suggested by these findings. One of the highest priorities identified by respondents was financial assistance to rebuild their practices. Because severe or complete damage to the work-place was associated with nonreturn, strong financial support incentives must be quickly established to promote the return of practicing physicians. For instance, consideration should be given to policies and programs that would provide immediate low interest loans or grants for rebuilding physician practices. These measures would aid struggling practices and support the reestablishment of health care in heavily affected areas.

Second, a disproportionate loss of primary care providers, including family and general medicine practitioners from designated disaster areas, must be addressed. Although comparative displacement data for the general population in the designated disaster areas are not readily available for the study period, specific incentives to attract the return of primary care providers to return should be considered.

A number of studies point to sharp increases in the number of uninsured or those who had lost access to insurance records following the storm.¹⁰ Along these lines, health care services for underserved populations should be prioritized to receive direct support to address the increased burden that uninsured patients impose on financially weakened medical practices. Programs that offer appropriate reimbursement to physicians for providing care to indigent and uninsured patients should be established as a standard protocol to assist in health care system recovery.

Third, the federal government has opened discussions regarding new grants and loans specifically earmarked for health and medical recovery, lack of access to the uncompensated care pool to those providing care, and bridge funding for health and medical staff salaries and operational costs with disaster-specific loans and grants.¹¹ Despite such measures, important financial constraints continue to impede the long-term health care system recovery. In response to future disasters, these types of initiatives must be expeditiously implemented.

In conclusion, this study identified a sizeable proportion of physicians who remain displaced following Hurricane Katrina as well as a lasting decrease in the number of physicians serving in the areas affected by the disaster. This, in turn, has broad implications for the long-term health care system recovery of the Gulf Coast. A comprehensive, regularly updated electronic contact list for physicians would assist representative organizations in monitoring physician relocation patterns, identifying information needs, and offering local support services to physicians. Although the plans elicited from respondents are subject to change based on many factors as the Gulf Coast recovery progresses, programs to address identified physician needs in the aftermath of the storm may give confidence to displaced physicians to return. Additional follow-up assessments may be useful in determining whether the identified patterns of physician relocation persist or change over time.

The authors thank Mindy Schneiderman, Ph.D., from the AMA for assistance in survey design and web-based implementation, and Sunny Chen and Dr. Gene Beyt, Department of Health Systems Management, Tulane University School of Public Health & Tropical Medicine, for review and revision of the survey.