America has two health care systems: One that is largely white; another that is largely black, brown and poorly administered.
That’s the troubling finding of two studies funded by the Robert Wood Johnson Foundation and conducted by the Harvard School of Public Health.
Fewer than five percent of hospitals provide care to more than half of all elderly African-American and Hispanic patients, and that care is often substandard, the studies found.
“When we see ongoing segregation in housing and education [in America,] it may not be surprising that we’re seeing very different administration of care in hospitals that serve blacks and Hispanics versus hospitals that mostly serve whites,’’ said Dr. Ashish K. Jha, M.D., M.P.H., the lead researcher on both studies. “But we’re not talking about [failures of] high tech medicine. This is basic stuff, like failing to administer aspirin or beta blockers to patients suffering a heart attack; treatments that we’ve known about for 20 years.’’
The latest study, released March 10 in the bi-monthly journal Health Affairs, focused on medical care for elderly Hispanic patients. It follows a similar study released in the June 2007 Archives of Internal Medicine on the quality of healthcare received by elderly African-Americans.
Researchers looked at hospitals in all 50 states, and found that elderly black and Hispanic patients often received substandard care for common but serious conditions like heart attacks, congestive heart failure and pneumonia. Researchers say their data suggests that the nation's healthcare system is racially and ethnically segregated, not just for the elderly, but across the board.
While the mix of hospitals serving black and brown patients varied, what remained constant for researchers were the factors contributing to lower quality care: large numbers of Medicaid and Medicare patients concentrated in hospitals that lacked sufficient staff, leadership, systemization or accountability. For Hispanic patients, language, and a lack of bilingual medical staff create an additional barrier to quality care.
In Miami-Dade County, where 60 percent of the population is Hispanic, and where virtually every hospital has large numbers of Latino patients, the study identified one hospital: South Miami Hospital, among the best care providers in the U.S. for Latino patients admitted with pneumonia.
The study identified another medical care facility, South Beach Community Hospital in Miami Beach, as among the worst for patients suffering heart attacks. That hospital closed in March 2006 after filing for Chapter 11 bankruptcy. It had been threatened with exclusion from Medicare and Medicaid fee coverage after being found in non-compliance by the U.S. Department of Health and Human Services' Office of Inspector General.
“It doesn’t have to be that way,’’ said Dr. Bruce Siegel, a research professor in the Department of Health Policy at George Washington University Medical Center's School of Public Health and Health Services, who heads another Robert Wood Johnson-funded initiative called Expecting Success (www.expectingsuccess.org). That initiative is aimed at improving cardiac care for black and Hispanic patients.
“We've focused on 10 hospitals that have disproportionate numbers of minority patients, to close the gap in care. We’ve been working for two years and have seen really dramatic results just by getting the hospitals to collect data on race and ethnicity – something they typically don’t do.’’
Siegel said that just by keeping track of how many minority and non-English speaking patients are coming through the door, hospitals can track and systematize the care they’re giving and make improvements.
Siegel said that at the start of the project, one hospital was only giving 10 percent of Latino patients the recommended heart medications.
“We’ve seen that raised to 80 percent,’’ Siegel said.
Another hospital in the program was apparently seeing virtually no Hispanic patients, until data gathering indicated that more than 500 non-English proficient patients were being seen each month.
Jha, the lead researcher on the studies, agreed that keeping adequate records is important, but he says the U.S. will also have to take a more comprehensive look at the way hospitals that treat large numbers of poor patients are paid.
“I think we need to look at our reimbursement schemes for hospitals that take Medicare and Medicaid, because that seems to be a key indicator in hospitals that are having difficulty providing adequate care,’’ Jha said, pointing out that hospitals that accept Medicaid often have difficulty getting reimbursed for more complex, life-saving procedures.
For consumers, he said, “I think the good news is that we have lots of information available for patients to look at before they choose a hospital. You wouldn’t buy a car without checking Consumer Reports, so you should treat your medical care the same way.’’
While the Harvard study paints a grim picture of the disparities in health care, Jha said he believes that with so much of the minority population concentrated in so few hospitals –just 25 percent of the nation's hospitals care for the vast majority of black and brown patients – the changes that must be made are manageable. He also pointed out that not all hospitals serving minorities and the poor are failing.
“We have a small number of hospitals that are doing an outstanding job of providing care,’’ he said. “We can use those as a model.”