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.