# Presentation: 385540

##  Discrimination in the Health Care System

**Separate and Unequal**
**Maxine Golub, MPH**
**Senior Vice President**
**The Institute for Urban Family Health**
**Project Administrator**
**Bronx Health REACH  **
**19th National Conference on Chronic Disease Prevention and Control**
**March 2, 2005**

**Notes:**

Good morning, I am delighted to be here to talk to you about the work of the Bronx Health REACH Coalition. 

## Outline

- Bronx Health REACH Coalition
- Seven Point Advocacy Agenda
- Barriers to Health Care

**Notes:**
My plan is to tell you a little bit about our Coalition and our Advocacy Agenda, and then discuss what we have learned about barriers to care for people of color in NYC.

## Background

- The mission of the Bronx Health REACH Coalition is to eliminate racial and ethnic disparities in health outcomes in the southwest Bronx by creating a movement of individuals, agencies, organizations, and communities, working together, sharing resources, expertise, information and services
- The initiative is funded by grants from the Centers for Disease Control and the New York State Department of Health
- The service area covers 4 zip codes – 10452, 10453, 10456 and 10457 in the southwest Bronx

**Notes:**
Our mission statement is very clear - we intend to build a movement to eliminate racial disparities. 

We are grateful to our funders, the CDC and the NYS DOH for their help.

## Bronx Health REACH Coalition Members

- The Coalition consists of more than 30 groups.
- 	They include:
- Community-based social service organizations
- Health care providers
- An academic research center
- Non-profit housing groups
- Economic development organization
- After-school program
- 15 faith-based organizations
- Advocacy groups for diabetes
- Non-profit legal groups

**Notes:**
The Coalition enjoys broad support - growing from 5 groups in 1999 to more than 30 today.

## Bronx Health REACH Initiatives

- Faith-Based Outreach Initiative
- Fitness and Nutrition Initiatives
- Grocer & Restaurant Outreach (Healthy Hearts)
- Community Health Advocacy Initiative
-  “Got Sugar?” Diabetes Education Program
- Public Health Education Campaign
- Cultivating Change in the Provider Community
- Action Committee - Legal and Regulatory Initiative

**Notes:**
Most Coalition activities are developed and operated by the member organizations. 
A few highlights include - 
 a FBOI with 15 participating churches of several denominations
 a fitness program for diabetics as well as a self-management support group led by peer educators, and 
 the production of a video called Voices for Health Equality. 
But what I plan to discuss this morning is the work of our legal and regulatory group known as the Action Committee

##  Bronx Health REACH Statewide Advocacy Agenda  

## Seven Point Advocacy Agenda

- End discrimination in health care facilities
- Create a more diverse healthcare workforce
- Provide health insurance for all
- Ensure culturally and linguistically competent care
- Expand funds for public health education
- Ensure accountability for charity care funds
- End environmental racism

**Notes:**
Our agenda includes 7 themes, culled from working with community residents, which we believe address the root causes of racial disparities in health outcomes.

Read list - 

I wish I had more time to discuss each of these, but I am planning to address only the first.

I hope you will pick up a copy of our newsletter for information about the rest.

## Discrimination in Health Care: Separate and Unequal

- 1.   Maldistribution of insurance coverage by race
- 2.   Segregation of the poor and uninsured (predominantly people of color) into different  institutions
- 3.	Segregation into different care systems within institutions, especially in our major teaching hospitals
- 4.   Failure of Managed Care to create open access
- 5.  Institutional subsidies (Bad Debt and Charity Care,  Indigent Care Pools) which fail to provide equitable access to care
- 6.   Inequities in payment by the Federal Government

**Notes:**
For the next few slides, I will share what we believe to be some of the causes of disparities in access to care for Medicaid recipients, the uninsured, and people of color in New York City, resulting in what can fairly be called “medical apartheid.”

##  1 -Maldistribution of Insurance Coverage by Race 

**Notes:**
The first issue on our list is the maldistribution of insurance coverage by race.    We all know that insurance is a major factor in access to medical care.  Studies have shown us that lack of insurance causes people to
Postpone trying to access care 
Experience delays in getting the  treatment they need
Have worse health outcomes
We understand that there are many other causes of racial and ethnic disparities in health outcomes 
Language, cultural and other communication  barrier
Lack of a diverse workforce & cultural competency skills Racism in the way providers make decisions about the care they offer people of color compared to whites, and 
Lack of trust that people of color have in the healthcare system, to name a few...
Still, lack of health insurance restricts access and is a major cause of racial and ethnic health disparities.	

## % Uninsured by Race

**Notes:**
People of color are roughly 70% more likely to be uninsured in New York City

29% of Blacks and Latinos are uninsured compared to only 17% of non-Hispanic whites.

## % Publicly Insured and Uninsured by Race

**Notes:**
Blacks are more than 2 times more likely to be uninsured or publicly insured than whites.

Hispanics  are more than 2 1⁄2  times more likely to be uninsured or publicly insured than whites.

So if insurance is an important factor in health care access and health outcome, then it is clearly a factor in why people of color have worse health outcomes than whites.

##  2 -Segregation of the Poor and Uninsured into Different Institutions

**Notes:**
Another impact of insurance status is that patients are segregated into different health care institutions. 
While  we don’t see any signs that say “Coloreds” and “Whites” hanging over the doors of our institutions, we accomplish nearly the same thing in New York City by discriminating based on insurance.
And while I am sure that you all know that hospitals never “dump” patients or “cherry-pick” those with private insurance, I am sure you will be amazed at how – magically – patients manage to sort themselves into the right buildings – even when those buildings are attached or within a  block or two of each other.

## Discharges by Expected Source of Payment(SPARCS Table IX 2001) 

**Notes:**
This chart shows 60 NYC hospitals lined up by the percentage of Medicaid and uninsured patients they take care of.

It runs from a low of 3.5% to a high of almost 90%.  

## NYC Public Hospitals bear the higher percentage of patients that are uninsured and Medicaid(SPARCS Table IX 2001)

-     Public Hospitals
-       Private Hospitals

**Notes:**
This chart shows that public hospitals are far more likely to care for those on Medicaid and who are uninsured. 
No surprise there, right? 
But how does this happen?
In NYC, public and private hospitals are often co-located within blocks of each other.  

## Jacobi (public) v. Montefiore Weiler(Distance: 2 blocks)Source: SPARCS 2001 Table IX

**Notes:**
The orange bar shows the percentage of uninsured and Medicaid patients discharged from Jacobi, a public hospital. The red bars are the private hospital two blocks away. 

No signs, right? How do people know??

## North Central Bronx (public) v. Montefiore Moses(Distance: Contiguous) Source: SPARCS 2001 Table IX

**Notes:**
Different neighborhood, two different hospitals.Same story.

## Bellevue (public) v. NYU(Distance: 1 Block) Source: SPARCS 2001 Table IX

**Notes:**
Again.
I have about 10 of these pairs, but I’ll stop here.

##  3 - Segregation of the Poor and Uninsured into Different Systems of Care within Institutions

**Notes:**
But this is only part of the story.

Even when people who are uninsured on Medicaid are seen in the private academic medical centers, the ambulatory care systems for specialty care are often structured as if there were two institutions operating in one facility.

Researchers with Bronx REACH surveyed three major medical school academic centers two years ago, and three more this year.  
Here are the major findings:

## Results of Hospital Survey

- FACULTY PRACTICE AND CLINIC DISPARITIES
- Almost all Academic Medical Centers we looked at operate two separate systems of care – largely based upon the patient’s insurance:
- Sometimes they operate in the same physical space at different times/days and sometimes in different spaces – but always with different models of care

## The “Faculty Practice” Model

**Notes:**
The private model of care is characterized by 
high levels of expertise
communication
continuity 
24 hour access
accountability

## The “Clinic” Model

**Notes:**
Alternatively, the “clinic model” demonstrates
less experienced providers
little communication between pcp and specialists
no continuity of care
no after hours or emergency access
little personal accountability

The result, is that people of color, with public or no insurance, end up in an inferior system of care, 
And are far more likely to experience lengthy delays to obtain higher levels of care  - whether its angioplasty or  transplantation 

## - 4 - Failure of Managed Care to Provide Open Access 

**Notes:**
This is one of our biggest disappointments, since managed care was supposed to be the great equalizer - 

## NY State Medicaid, Child Health Plus and Family Health Plus contracts all require that ...

“All training sites must deliver the same standard of care to all patients irrespective of payer.  Training sites must integrate the care of Medicaid, uninsured and private patients in the same settings.”

- “All training sites must deliver the same standard of care to all patients irrespective of payer.  Training sites must integrate the care of Medicaid, uninsured and private patients in the same settings.”

**NYS Managed Care Contract Language forbids segregation based on insurance status.....****but remains unenforced.**

**Notes:**

But it didn’t work.  Many managed care patients are seen in the same clinics where they received care previously.  

And in spite of the contract language that requires institutions to provide the same care to all, there is no monitoring of compliance by the plans, or by the State OMC

## Results of Hospital Survey

- MANAGED CARE can limit access when it is supposed to do the opposite
- Each hospital participates in a limited number of Medicaid, CHP, and FHP programs
- Specialty care may not be accessible in a neighborhood hospital if a patient belongs to a managed care plan that has not contracted with that hospital
- Many hospitals contracted with only a few plans. The Children’s Hospital of Montefiore, for example, participates in only 4 of the 17 health plans licensed in the community

**Notes:**
Additionally, many institutions participate in only a few plans - often the ones they are principals in - and so many many patients still can not get in the door.

The greatest disappointment in the Bronx is Montefiore’s world renown Children’s Hospital, billed, when it was being built, as a center for the children of the Bronx. In fact, it accepts only 4 of 17 plans, and no uninsured patients.  

##  5 -Institutional Subsidies(Bad Debt and Charity Care, and Indigent Care Pools)Fail to Provide Equitable Access to Care

**Notes:**
The distribution of Bad Debt and Charity Care Funds is not aligned with the volume of true charity care provided by hospitals.

 In NY, institutions are not required to differentiate between bad debt, or uncollected fees often related to poor business practices, versus true  charity care. 

## Institutional Subsidies

- New York State hospitals received $847 million in 2002 to cover the costs of bad debt and charity care, but does not allow individuals to seek care using these funds
- The state has no mechanism to allocate funds to assure that funds are being used to provide services to those who are underinsured or uninsured, the majority of whom are people of color
- Hospitals are permitted to bill patients full charges and sue for payment while still collecting enormous subsidies

**Notes:**
We need to tie the distribution of charity care dollars to individual patients, and make sure that patients are informed of its availability.
We need to make sure that uninsured patients are not billed at higher rates than Medicaid patients
And we need to prohibit hospitals from suing patients for payment while collecting subsidies for their care

##  6 - Inequitable Payment for Medicaid Services by the Federal and State Governments

## 
The Federal Government has two major health care programs - Medicare for the elderly and disabled and Medicaid for the poor

- The Federal Government has two major health care programs - Medicare for the elderly and disabled and Medicaid for the poor

**New Pt Comp Consult    Estab Pt F/U**

**Notes:**
The government has set up two systems of reimbursement -
Medicaid for the poor and
Medicare for the elderly.

Medicare pays a private doctor $250 for a comprehensive visit to a new patient and  $65  for a follow up visit, while Medicaid pays the same doctor $22.50

This disparity insures unequal access to care and perpetuates the clinic system I described earlier. 

## 1998 Medicaid Payments per Recipient, by Race 

**Notes:**
This slide shows MA payments by race.

Its true that much of the care for whites is related to long term care. The question is, why don’t other races need long  term care? And the answer of course, is that they die younger.  The average age of death for
 whites is __ blacks is __
and Latinos is __

## CONCLUSIONS

- There are gross inequities in the delivery of  care
- Inequities start with differential insurance coverage
- Institutions sort patients by insurance, resulting in  de facto racial sorting
- We cannot eliminate racial disparities by providing inferior care to our patients
- We cannot sort patients into different institutions, provide them different systems of care with different quality and then expect the same health outcomes
**	****“****Be the change you wish to see in the world.”**
**                                               ****- Gandhi**

**Notes:**
Go back and look at your institutions policies and practices.  
There is hope.
In some institutions where there is is segregated care there are individual department heads that have completely integrated their department’s out patient work.  Leadership counts.

Take leadership in your own institution to make policies to increase access, eliminate disparities in care – and call the administration every time something works against this goal – payments required up front, sorting by insurance, etc.

## REACH Recommendations

- Develop enforcement mechanisms through the Patient Bill of Rights and Certificate of Need (CON) Process
- Equalize reimbursement rates to create access to equal quality of care for Medicaid recipients and the uninsured
- Mandate the collection of  race data through the establishment of a Commissioner led collection committee