Saturday, November 21, 2009

How to Guarantee Disparities in Health Outcomes: A Primer

Bradford Gray, PhD, a distinguished health services researcher has published a very important study which demonstrates yet another reason why our health care system is designed perfectly to get the disparities in health outcomes that result.(1) Dr. Gray and his colleagues concluded that “minority patients in the New York City area are significantly less likely than whites to be treated at high-volume hospitals for cancer surgeries, cardiovascular procedures, and other services for which high volume and positive outcomes are related”. In other words, racial and ethnic minority patients are much more likely to get essential procedures done at hospitals that do fewer of them per year – a factor well known to contribute to poor health outcomes.

For those of us who provide health services in New York City none of this is a terrible surprise. We all know that those specialty hospitals that advertise on radio and television that they provide the best care in their field – Memorial Sloan Kettering for cancer, Joint Disease and the Hospital for Special Surgery for orthopedics, NYU’s Rusk Rehabilitation Institute and Calvary Hospital for end of life care – all have among the lowest rates of admissions for the uninsured and those on Medicaid.(2)

There are many reasons for this, as we have come to learn. For one, most Medicaid patients are in managed care now and hospitals and managed care companies must negotiate rates in order for the hospital to be considered "in-network" and thus accessible by people who have chosen to enroll in that managed care company. But as we have learned from folks at Sloan-Kettering, no Medicaid managed care company want to contract with them for their Medicaid enrollees. With a reputation as the only specialized cancer center in New York City, a single managed care company that puts Sloan-Kettering in its network will find itself the plan of choice for people with cancer, thus driving up its costs and reducing its profits. The same dynamic will take place for the other specialty hospitals as well. Do patients know, when the sign up for a particular managed care plan that it will likely restrict them from recieving services at the highest volume specialty hospitals if and when they come to need them? I think not. Young people don't sign up for a managed care plan thinking that they might develop cancer - yet when they do - and find themselves unable to go to a specialty hospital for treatment - they unknowingly become a potential victim of health disparities - treatment at a lower volume hospital with a potentially poorer outcome. Sad, when we are talking about the basic human right - the right to live.

There are no villians here. The facts are that we continue to create - through policies in the State, through limitations in funding, through a competitive rather than a cooperative marketplace of health plans, hospitals and doctors - a system that perfectly produces the disparities in outcomes that we achieve.

Bronx Health REACH is a consortium of over 40 community and faith based organizations that has been working in the Bronx for over a decade to reduce – no, eliminate – disparities in health care treatment and health outcomes. We have been working to change the policies which create racial disparities in out-patient care in the voluntary hospital sector in New York City. In facilities that operate “clinics”, the clinics are the places where the poor are treated in a system that provides care that is inferior in many aspects to the “private” care given in other parts of the system. Students, interns and residents - often supervised by a rotating group of attending physicians – are the main health providers that patients see. Troublingly, these doctors rotate monthly through the clinics making continuity of care almost impossible. The clinics have very limited ability to coordinate care with referring community physicians, another cause of discontinuity. Obviously, these doctors are also the least experienced, and these factors together explain, with an unproven yet logical extension of Dr. Gray’s research, another reason why outcomes can be expected to be worse. Everything that contributes to inferior care contributes to the premature death and disability people of color in New York experience.

Like I said before, the system of care in New York is designed to get just the disparate outcomes it achieves. Let’s redesign it.

1. B. H. Gray, M. Schlesinger, S. M. Siegfried et al., Racial and Ethnic Disparities in the Use of High-Volume Hospitals, Inquiry, Fall 2009 46(3):322–38
2. New York State SPARCS Hospital Discharge Database,Table IX

Saturday, November 14, 2009

For Medical Students: Primary Care, the Uninsured and Painful Lessons that Lie Ahead

On a rainy and blustery evening last week, I had the pleasure of speaking to an amazing group of first and second year medical students at Downstate Medical School in Brooklyn – part of the State University of New York. I am not sure whether they came for the Thai food or to hear me speak but I had the opportunity to tell stories of my medical school, residency and practice experiences – each highlighting some of the fundamental values underlying primary care. My message was that patients are increasingly demanding primary care as a trusted way of negotiating an otherwise incredibly confusing and fragmented health care system. I stressed that primary care physicians must stay focused on the needs of their patients above all else and that our loyalty and responsibility towards our patients must always remain first and foremost in our minds and actions – unfettered to the maximum extent possible – by advertising and loyalties to our hospitals or peers.

As I wrapped up my comments two questions came from the audience. The first, quite predictably, concerned my feelings about the “government controlling health care” and how I felt about that. I asked if the young woman asking the question from the very back of the room was asking about the much debated “public option” in the current health care plan passed by the House last week and she nodded affirmatively. I explained that the plan does not call for the government to control health care, rather that we would be adding another type of government subsidized and managed health care plan to the already existing government plans – namely Medicaid and Medicare.

A tougher question came from a young man in the front of the room who asked how our community health care system could survive financially taking care of the number of uninsured that we currently cared for. And that question truly cuts to the heart of the health reform debate, though I wasn’t fast enough on my feet to realize it at the time. Our 24 site community health care center network in Manhattan, Bronx and the Mid-Hudson Valley cares for over 10,000 uninsured individuals and provides them with over 35,000 visits a year. I explained that to pay for this we literally cobble together funding from dozens of sources. Our Federal 330 grant pays for some, New York State indigent care funding picks up another piece, and grants that support the care of the Homeless, the care of some uninsured patients affected by HIV and dozens of other grants for sub-groups of our uninsured patients – all go to support this work and keep us afloat. I stood there proud that our organization – the Institute for Family Health – had been able to accomplish this.

Yet I missed a real opportunity to underscore the fundamental reason we need health reform in this country. People need health insurance. Our country cannot depend solely upon health centers like ours as the safety net for everything patients who are uninsured need for their care. They must have coverage to pay for all the essential health care services they need. Primary care is the front end of an entire health care system which must provide access to people for diagnostic services, treatments, hospitalizations and medicines. With people of color 2 to 3 times more likely to be uninsured in New York City providing insurance for everyone is an absolutely essential step towards eliminating racial and ethnic disparities in health outcomes. And with primary care providers already struggling to create viable practice models in underserved areas, only full insurance coverage of the people who need these providers can sustain these practices and attract new doctors to these areas.

I am sorry I missed the opportunity to explain more to the students in Brooklyn last week about the failings of our current health care system. But I am not worried that their education will be lacking for very long. Soon the students will begin their clinical rotations in the hospital and there they will no doubt experience, first-hand, the failings of our current system to provide health care for all our people. They will see people suffering the effects of poorly treated chronic diseases – losing their legs and their kidneys to long-standing diabetes. They will see people with cancers that would have been curable if only they had been detected earlier. They will see people with advanced infections that have gone untreated for days or months and now require prolonged hospitalizations. These lessons will hit hard and perhaps some of them will understand and will choose to become the next generation of primary care physicians and the new champions for needed change in our health care system.

Saturday, July 25, 2009

Sexism Effects Clinical Decision-Making as Well

In repsonse to my last two blog posts, a number of readers responded that women, not just people of color, experience bias and disrespect in the health care system. This brought to mind a study done over 20 years ago by a brilliant colleague of mine, Dr. Jonathan N. Tobin. His 1987 Study published in the July 1 issue of the Annals of Internal Medicine (Volume 107, pp 19-25) revealed that there was substantial "Sex Bias in Considering Coronary Bypass Surgery".

The abstract of that study reads in part:
" In a study of 390 patients consecutively referred for nuclear exercise testing, abnormal results found in 31% of the women and in 64% of the men affected physicians' decisions to recommend catheterization in men only; 4% of the women with abnormal radionuclide scans were referred for catheterization compared with 40% of the men (p < 0.001). This 10:1 ratio was independent of age."

Gender bias, racial bias, bias against obese individuals, bias against those who speak a language other than English - all affect the care that patients recieve in the health care system. And they have secondary effects as well - as some of the commentors on my previous blogs pointed out - they make one loathe to go to the doctor at all. And with no medical visit, the odds are that people neglect needed preventive care and comprehensive care for chronic conditions. Can this problem be helped through training? Perhaps. But we have a very long way to go. And tragically - for decades since the Tobin article was published, there is little evidence that we have made any substantial progress.

Wednesday, July 22, 2009

CNN Report on Aparthied in Medical Care in New York City - a follow-up note

(The message below was posted on Anderson Cooper's blog in response to many comments recieved about the show that aired on July 20 on AC360. It is scheduled to air again on Saturday July 25 on Dr. Sanjay Gupta's House Calls)

My name is Dr Neil Calman and I was the physician interviewed by Dr. Gupta for the segment on racism in medical care. For those of you who may have missed it you can see it by clicking on the link below:

First, I would like to express my appreciation to CNN, Anderson Cooper, Dr. Sanjay Gupta and his senior producer Caleb Hellerman for a thoughtful and accurate portrayal of the difficulties people of color in New York (and certainly in other parts of the country) have in obtaining good medical care. This report was the result of an investigation of the named hospitals in New York City done more than a year ago and which formed the basis of a complaint to the New York State Attorney General.

I also sincerely appreciate the many comments on CNN’s blog from patients – many of whom were not Black - who were also misdiagnosed, mistreated or otherwise received inadequate care and concern for their medical problems. These stories require our attention as American’s receive grossly inadequate care while our country spends 2 to 3 times more per person than some other countries that achieve far better outcomes and whose residents live longer and healthier lives. That is why we need health reform and need it now. It also speaks to the need for more primary care physicians – so every person in America that wants one, can have an ongoing, supportive relationship with one main provider who cares for almost all their medical needs and advocates for them when they need to see a specialist or when they need specialized care or a special procedure.

I want to address the issue that being Black is not what the CNN story was about but rather was the same story that could be told by poor or uninsured white people as well. Telling the story of only a few Black ministers in the Bronx was not meant to suggest that the problem was exclusively one faced by people of color. The people interviewed were just examples of over 100 phone calls made and recorded by our researchers who looked at how people were sorted into different models of care in New York City based upon the type of insurance they have. In New York City, because of the predominance of Blacks and Latinos among the uninsured and those on Medicaid, sorting people of color into systems with less well trained providers, no continuity of care, no emergency call systems and no communication back to the patients primary care provider – all contribute to the inadequate medical care that many receive and contribute to the poorer health outcomes Blacks experience.

Some people say that its all about education – or poverty – or lack of insurance. In fact, imagine that each of these things – education, financial well-being and good insurance coverage – are all things people need to get the best medical care. And also imagine – what hundreds of published studies have shown – that race, independent of all these other factors, is a predictor of poorer health care processes and poorer outcomes. If you imagine this, then you can understand that the question is not which of these factors is more important – but how many strikes do you have against you when you seek medical care. Race is one factor and being Black or Latino is one strike. Being poorly educated is another strike – especially when that means a poor understanding of the diseases that are important in your own preventive care plan, your family’s health or the diseases most prevalent in your community. Lack of financial means may create a situation where you put off, sometimes indefinitely, needed preventive care measures or put off buying the prescription drug not covered by your health plan. And being uninsured is a fourth strike as it is the greatest predictor of bad health outcomes.

Racism in health care is a common experience of people of color so let’s stop saying that race does not matter. We know it does. It is one very important factor in why people get bad medical care. . So is poor education, poverty and lack of insurance.

Our health care system needs to do better. We need to fight racism in medicine wherever it occurs and that is what the CNN story is about. We also need to get health reform passed now! That will largely fix the insurance issue. We need many more primary care physicians so everyone can have a trusted physician they know over time and who will care for all their basic medical needs. And we need a better campaign to educate all America about the importance of preventive care, good care for their chronic illnesses and about the health behaviors that can help them lead healthier and longer lives.

As President Obama points out – this is not a debate over politics. Everyone knows we need to fix our very broken health care system. Everyone has a horror story to tell somewhere in their personal experience or the experience of their friends or family. We have to do better than this and we can.

Saturday, July 18, 2009

CNN AC360 Dr. Sanjay Gupta Covers our Attorney General Complaint Re: Dsicrimination in NYC Hospitals

Bronx Health REACH Attorney General Complaint to be featured on CNN's AC 360
Segments Produced by Dr. Sanjay Gupta – Monday July 20
10pm-12midnight [1]

Monday night, July 20, 2009, on CNN’s Anderson Cooper 360, Dr. Sanjay Gupta will be airing a two-part segment on racial discrimination that results from separate and unequal care provided by private teaching hospitals in New York City. Since 2005, Bronx Health REACH has shown, through its research efforts, that in many institutions in NYC, people covered by Medicaid and those who are uninsured are routinely treated in separate hospital-based facilities and by different providers than those who have private insurance. Furthermore, inadequate after-hours coverage, absent communication back to referring providers, and limited appointment availability all create disparities in care and lead to worse health outcomes. Because 16 times as many African-Americans and Latinos in the Bronx are covered by Medicaid or are uninsured compared to Whites, this creates de facto discrimination based upon race, a practice that is both immoral and illegal.

As you may remember, in June 2008, Bronx Health REACH, a coalition of community-based, faith-based and other organizations led by the Institute for Family Health, filed a civil rights complaint with the Office of the Attorney General of New York State. This complaint and the allegations contained in it were prepared and filed on behalf of Bronx Health REACH by New York Lawyers for the Public Interest (NYLPI).

Through multiple visits to New York accompanied by his producer and film crews, Dr. Gupta has interviewed faith leaders, patients, and REACH staff to bring this issue to light. The REACH Coalition has been working in the Bronx for nearly a decade to reduce racial and ethnic disparities in health outcomes for patients with diabetes and heart disease. Our hope is that national exposure of this issue will help end these practices in New York City and will make sure that equality in health services becomes part of our Nation’s health reform agenda.

REACH began its investigation of the out-patient referral practices of three hospitals named in the complaint - Montefiore, NY Presbyterian, and Mt. Sinai – after hearing multiple stories shared by patients in the coalition’s member organizations, as well as learning the experiences of primary care providers seeking to obtain out-patient specialty care for their patients. In consultation with researchers from New York University, hundreds of scripted phone calls were made and recorded over a period of months to the physician referral lines of the named institutions. In addition, REACH obtained the recorded testimony of a number of patients who experienced this discriminatory care and suffered because of it.

Our research findings show systematic channeling of patients into different care systems based upon their type of insurance – or lack thereof. As documented in our complaint and other findings over the years, it is commonplace for New York’s voluntary teaching hospitals to separate patients at the point of entry to their outpatient practices into two systems of care: their clinics and their faculty practices. Worse yet, while the faculty practices function the way we would all want to get care—with good continuity, reports sent back to the primary care providers, after-hours call by the group’s doctors, and access to the best that New York medical care has to offer—the clinics offer patients a rotating group of residents and fellows with little or no continuity of care; provide no communication with the primary care providers who referred their patients there for care; and often refer patients to the Emergency Room if they have questions or problems after-hours. Given this difference in care systems, differences in outcome should come as no surprise.

I know you all believe we can do better than this. We must do better, particularly as we promote the concept of medical homes for patients throughout New York State, and health reform at the national level. The vast sums of money that the State and Federal government put into health care for those who receive Medicaid and the uninsured obligate us to do better. In fact, recent increases in Medicaid out-patient rates mean that hospitals are now, in many instances, getting paid more by the State than private insurance is paying for their covered patients – and getting inferior care.

For far too long the health care system has blamed patients for their own poor outcomes, pointing to their delays in seeking care, their inadequate follow-up with appointments and their lack of compliance with treatment. The experience of the more than 100 primary care providers at the Institute for Family Health, and the experience of the members of the organizations of the Bronx Health REACH coalition tell a different story. New York’s voluntary teaching hospitals have created clinic systems that are difficult to negotiate, that provide care that patients quickly realize is not the best the institution has to offer, and that severely jeopardize their health and their lives. While these factors alone do not explain the 7 to 8 year decrease in life expectancy that Blacks and Latinos experience in the U.S., nor the increase in hospitalizations for conditions that are treatable in office settings and the excess morbidity and mortality suffered by people of color for almost every disease studied, we must change those aspects of our health care system that contribute to these tragic and disparate outcomes.

Filing a complaint with the Attorney General was a last resort to fix a problem I have been addressing on behalf of Bronx REACH and the Institute for nearly a decade. I have met personally with leadership from a number of voluntary teaching institutions in New York City, have presented findings of our studies at dozens of professional meetings, have had multiple discussions with the Greater New York Hospital Association leadership, and have discussed this issue with the former Commissioner and senior staff of the NYS Department of Health on multiple occasions over the years. In 2005, we published a report Separate and Unequal: Medical Apartheid in New York City, which received substantial press coverage and resulted in a number of public responses from voluntary hospitals. In private discussions, many agree that systems should be changed, but there has been no motivating force to stimulate this change.

I expect that the institutions named will once again be highly critical of the complaint and the CNN report, and will defend their practices in the same ways they have previously. First they will claim that faculty practices are not part of the institution but are merely affiliated private practices. This argument is both spurious and irrelevant. Personnel who are paid by the hospital and staff their physician referral lines, facilities that are licensed to the hospital, and systems that the hospital has established are sending people down different paths of care based upon their insurance status.

Next they will claim that billing requirements make it essential that clinics are run separately. This is also not true. Nothing prohibits privately insured patients from being seen in a hospital licensed out-patient facility, and doing so would not jeopardize private insurance payments in any way.

Finally, some will claim that they will be unable to attract patients from the suburbs and from outside the country if the services they offer must be integrated with the care of clinic patients. This is perhaps the most disturbing rationale of all. I invite leadership of these institutions to come to our Institute practices where corporate executives, patients referred from our homeless centers for follow-up, and a broad cross-section of New York comes for care, sit in the same waiting room and all have access to the best care we have to offer. As health care providers we, of all people, need to demonstrate a commitment to ending discrimination based on insurance status with the disparate impact it has on racial and ethnic minorities.

Traditions and long-standing systems do not die easily, but this one can and must. We have encountered a number of departments at each of the institutions where department leadership—either for moral or practical reasons—have decided to integrate the care of all patients into the same system. Hospital leadership should take note of these successful models in their own institutions and adopt their practices broadly and completely. Nothing less than that will provide our patients with the care they deserve and nothing less than that will help to eliminate the disparities in care that continue to exist in our institutions.

Please make time to watch Anderson Cooper 360 on Monday night, and share your thoughts with us by commenting on this blog. Please join me in encouraging our colleagues in voluntary teaching hospitals across New York City to address this longstanding injustice and inequity in care.

[1] As with all news broadcasts, changing current events may necessitate changing the broadcast date or time of these segments

Wednesday, April 29, 2009

Who will Represent America’s Poor as We Move Toward Health Reform?

Both the Administration and the Congress have been gearing up for health reform for many months. There are some good signs that both branches of government are taking health reform seriously. The President has spoken out on many occasions on the need for health care reform which includes a transition toward electronic health records on an accelerated timeline. Congressional committees have held a number of hearings and discussions. But the voices of our most underserved populations and those who serve them directly have largely been absent. This must change because poor people in our country, the uninsured, and people of color are sicker and die disproportionately because of lack of access to care and differences in the quality of care when it is given. Many in our most vulnerable communities use the emergency room as their only source of primary care because they have no health insurance, speak languages other than English or lack access to adequate preventive and primary care services.

As a result, those most at risk experience poorer health outcomes for almost every chronic condition studied and for most surgical procedures. This is the definition of health disparities and why our nation experiences the high cost of treating them. As our nation becomes even more of an ethnic melting pot, these disparities will only get worse if we don’t get health reform right this time around. By 2050 nearly one in two Americans will be persons of color – folks who experience higher levels of chronic disease, shorter life spans, less health insurance and generally poorer health due to lower participation in health insurance plans and less access to care.

But where are these voices in the current health care debate? Both the Administration and the Congress hear regularly from a chorus of organized representatives from the health care industry as they should. But the voices of those most affected by health disparities and the voices of those providers, hospitals and insurers who are most knowledgeable and most involved in their care are largely missing from the current national debate. A recent Senate panel on health care reform included some of the most distinguished names in the health care community. Unfortunately these panels did not include a single representative from underserved communities or those who serve them. If we are to truly reform health care in this nation, this must change.

This Administration and our Congress must enact measures that implement coverage and access for those who cannot now afford health coverage while paying attention to the worsening shortage of primary care providers in our nation’s poorest urban and rural communities. The use of electronic health records and health information technology must also focus on the maximizing the affects of these changes in underserved communities.

As the Administration and the Congress move toward health reform, they must widen the net of the communities and their representatives to whom they are talking. In the establishment of the Health Information Technology Committee of the Department of Health and Human Services, a designated seat was established for "An expert in the health of vulnerable populations". I am pleased to have been appointed by the Administration to that position and look forward to input from my colleagues from a broad spectrum of safety net provider organizations and from community and faith-based organizations to help bring the voice of America's most medically underserved folks into the critical discussions concerning the widespread deployment of HIT. What an exciting time this is and what a great responsibility we have to get it right!