Race and Health Coverage: Medical Apartheid?

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I’ve invited Niko Karvounis, a colleague at The Century Foundation, to guest-blog. Niko is currently a Program Assistant at the Foundation and an Alumnus Senior Fellow with the Roosevelt Institution. His post follows below.

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Recently I was handed a report from Bronx Health Reach (BHR) entitled “Separate and Unequal: Medical Apartheid in New York City” that reveals some startling inequities right here in the so-called capital of the world.

Bronx Health Reach is a coalition formed by the Institute for Urban Family Health, with the mission of examining and addressing racial and ethnic health disparities in the southwest Bronx portion of NYC.

At the local level in the Big Apple, these disparities play out through discriminatory care tied to health coverage. Since “health insurance is a major determinant of access to medical care,” poor insurance increases the probability of “delayed care and poorer health outcomes.” And in NYC, health insurance status is closely linked to race: “52 percent of blacks, 63 percent of Latinos” and only “24 percent of whites are uninsured or publicly insured.”  This skewed distribution of health coverage ultimately “creates a de facto sorting of patients by race.”

The most compelling evidence of apartheid can be found in the records of medical institutions which reveal the characteristics of patients that they admit and discharge.

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Do You Want to Know That You Will Be an Alzheimer Patient in Two to Six years?

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Yesterday The New York Times reported a medical breakthrough: “the development of a blood test that can  accurately  diagnose Alzheimer’s disease, and even do so years before truly debilitating memory loss.”

Well, “accurately” may be a bit of a stretch. As the Times explained, the test is about “90 percent accurate in distinguishing the blood of people with Alzheimer’s from the blood of those without the disease” and “about 80 percent accurate in predicting which patients with mild memory loss would go on to develop Alzheimer’s disease two to six years later.”

Then, the Times acknowledged, there is one other problem with the test:  “At present, treatments for Alzheimer’s disease are not very effective.”

So why exactly would I want an early warning that would give me two to six years to contemplate what it will be like to observe my mind dissolving? (Of course I could comfort myself with the fact that the test is only 80 percent accurate, but somehow I suspect that would only compound my anxieties.)

“There are people who want to know what their future holds so they can plan their estates and lives,” Dr. Sam Gandy, a professor at Mount Sinai School of Medicine in New York who is chairman of the medical and scientific advisory council of the Alzheimer’s Association, told the Times.

Right, this is an estate planning tool.

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When Women and African-Americans Receive Better Care Than White Men

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Last week a new study in the Journal of the American Medical Association documented yet another case of discrimination in American medicine. It turns out that blacks and women suffering from heart disease are much less likely than white men suffering from a comparable level of disease to have a defibrillator (a cutting-edge device that uses a jolt of electricity to shock an erratically beating heart back to a normal rhythm) implanted in their hearts.

But as Merrill Goozner points out at GoozNews:  "Guess what? They may be the lucky ones, at least when it comes to implantable cardioverter-defibrillators (ICDS) . . ."

The study showed no benefit for the white men who received the implant. Below, Merrill’s analysis, plus his comment (from a separate post) on the need for more and better research into the effectiveness of new drugs and devices:

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More Thoughts On the Hospital Building Boom

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A Startling Insider’s Look at What Happens to Patients Who Stay in the Luxury Suites of a Prestigious Hospital 
             
         

Last week, thehealthcareblog.com (THCB) asked if they could put up my post about the hospital building boom below where I ask “Can we Afford the Waterfalls”– and all of  the other hotel-like amenities that new hospitals are beginning to offer. Do we really need grand pianos, valet parking and all-private rooms—especially in hospitals that don’t yet have electronic medical records? (See my original post here)
         

Quite a few readers at THCB commented, with a number voting “yes” for the
amenities.  But one young doctor said “no”—and then offered this startling insider’s  view of  the care patients do and don’t receive on the luxury floor of one prestigious hospital:

“Maggie’s right-on regarding the disconnect between hospital frills and quality of care…

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How Not-For Profit Hospitals Hooked on Growth Can Help Bankrupt the System

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In response to the questions I raised in two posts below about the hospital
building boom and whether we need—or can afford—hotel-like amenities, Dr. Terry
Bennett sent HealthBeat the story below. It’s a provocative insider’s look at
how a local hospital is raising the money for an “expansion” that, according to
Bennett, seems to have very little to do with improving the health of its
patients or the local community. Part problem is that CEO’s of non-profit
hospitals have begun to think like CEO’s of for-profit corporations: growth is always
good.

“If you own all of the doctors’
practices that refer to a community hospital—as the CEO of our local hospital does–
you can dictate where, when and for how much every single patient is seen,”
Bennett writes.” For example, you can make sure that all urgent cases are seen
in your hospital’s ER at $1000 a head. (Medicare and Medicaid pay less than a
grand for a "bare bones" ER visit, but if you order an EKG, an x-ray
or two, and a few lab tests, you can push the visit up to over $1000).

“Do that 100 times a day
and you have millions [of dollars] which you need to cause to vanish as quickly
as possible. [Otherwise the Centers for Medicare and Medicaid services may
question how a not-for-profit could be making such rich profits, and start to
examine your books.] Thus the Atria, the waterfalls,the new facades, the many
other flashy dashy add-ons, the services no body really needed.

“The CEO of our local hospital hates me.
Because my patients can reach me 24/7, I have the lowest ER admission rate
of any physician on the staff at my local hospital. I treat over the phone, see the next day, am always on the prevention line of
chatter, etc. [In other words Dr. Bennett is not helping the CEO fill the
hospital’s coffers].

“Meanwhile, our hospital, is in the midst of a $45 Million ‘expansion’— no
new beds, no new services, but $45 million is being buried, and ‘non profit
status’ is preserved. It is happening in almost every community across the USA.
Such antics make any healthcare budget, Medicare, Medicaid, or HMO, completely
unpredictable and are bankrupting the entire present system and all of its
budgeting assumptions—and will continue to do so until forcibly stopped.”

Dr. Bennett also included a copy of an Op-ed which originally appeared in two
New Hampshire newspapers, the
Portsmouth Herald and the Rochester Times. Below, an edited version:

Health care issues in the new millennium
By Dr. Terry M. Bennett

It seems like only yesterday, but it was in fact 16 years ago, 1992, when I
ran for a New Hampshire Senate seat proposing a single-payer Medicaid-based
national health care plan using our Social Security numbers for identification.

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Are We Willing to Accept a Two-Tier Hospital System?

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Yesterday, I wrote about the hospital-building boom and suggested that we may not need it—and more to the point, we may not be able to afford it.

In my description of how hospitals are adding costly amenities like waterfalls and all-private-rooms in order to woo well-heeled, well-insured patients, I suggested that the money might be better invested in computerized medical records or Level I trauma units. (In some parts of the country, trauma units are spaced so far apart that if you are in a car accident, there is a real danger that the unit will be too far away to be of any help.)

Barry Carol responded, agreeing that safety should come first, but also arguing that the private rooms help prevent infections. As for the waterfalls, he noted that “while they may make good journalistic copy as illustrative of frills,” given the high cost of hospital construction “they probably get lost in the rounding as a cost factor.” See his comment here.

Because Barry had raised a number of good points, and because the hospital boom is such a large and crucial subject, I decided to return to it today while responding to his comment.

Barry—

I’m afraid the waterfalls are more than good copy for journalists.. Similar amenities are being included in hospital construction across the country–and it adds up.

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The Hospital Building Boom: Can We Afford the Waterfalls?

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In Money-Driven Medicine: The Real Reason Health Care Costs So Much I talk about the nationwide hospital building boom—and ask two questions: Can we afford it? Do we need it?

In many regions, suburban hospitals have been reaching for big-city business. “What we have to do to maintain our position in the markets is to keep adding services,” explained Westchester Medical Center CEO Ed Stolzenberg. “That’s the whole reason we went into liver transplants.”

Did the resident of Westchester Country (just outside of New York City) need a local hospital doing liver transplants? Just how many transplants would a Westchester hospital do? Would such patients be better off at a high-volume medical center in Manhattan where “practice makes perfect”?

Those questions didn’t seem to come up.  The CEO knew that transplants would raise the hospital’s image.

Across the nation, as not-for-profit hospitals set out to invest in new construction and equipment, decisions seemed to be market-driven—but  not necessarily driven by the local population’s medical needs.  Instead, they were powered by the hospital’s need for market-share.

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Employers and Healthcare: “Which Frogs A-Leaping?”

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At “Healthcare Renewal” (hcrenewal.blogspot.com) Brown University’s Dr. Roy Poses recently posted a thought-provoking piece about the Leapfrog Group, an employer group that has made its reputation pushing for higher quality care.  Poses points out that nearly 30% of the members of Leapfrog are healthcare corporations, and notes that this might skew their view of healthcare’s goals:
 

“One would expect that companies who make money by providing health care goods and services may have different ideas about health care costs and quality than companies who do not do any health care related business” said Poses in his post.

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Inside the FDA

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I was speaking to a source inside the FDA recently and he explained that since the FDA has committed to reviewing applications for approval of a new drug within 10 months, drug-makers have been submitting “shabbier” applications that contain less evidence about risks and benefits.

“For the drug-maker it’s a gamble. The company is betting that, because we want to make the 10-month deadline, we won’t send the application back,” said the source. And often, he acknowledged, the drug-maker is right. “If you find a problem or there is something missing and it doesn’t seem terribly material, there is a tendency to overlook it. Because if you don’t it will just delay the whole process.”

In the past, he adds, a company submitting an application knew that if the application wasn’t up to snuff, the FDA would send it back. But those standards have fallen: “Now we send it back [only] if it’s really crappy.”

We also talked about direct-to-consumer advertising and why many in the pharmaceutical industry resisted the suggestion that they wait two years before trying to sell a new drug directly to the public. “There is a saying in the industry,” he confided, “[that] you want to get doctors accustomed to using a new drug while it still ‘works’—while it’s still the latest and the greatest.”

In other words, drug-makers want doctors to begin using the drug before everyone discovers that it is not quite the miracle cure that some hoped it would be. Knowing that it takes time to discover the risks of a drug, doctors might not be so quick to take up the absolute newest thing on their own. That’s why companies like to go to consumers who they hope will push their doctors into trying the new products before all the risks are known.

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Preventing Hospital Errors by Howard C. Berkowitz

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I have asked Howard Berkowitz to guest-blog on hospital errors.

Howard is in an unique position to write on this topic because he consults on
medical information systems for hospitals and also has been a long-time
patient. Over the years, he has taken an unusually detailed decision-making role
in his own care for heart diseases and diabetes which, he says, “has kept me
going, with bad heart genetics, at least 17 years more than my father.”

Howard also reports that “when no one else would coordinate my mother’s complex
cancer care, I did so…and I know what it is to preserve the semblance of
life, when only pain remains. Complex pain management is also one of my
interests; too few doctors know that pain should always be controllable.”

As a result of his own health problems and his parents’ illnesses, he has spent
more time in hospitals than anyone would ever want to endure. But unlike
most of us, he understood what was going on. Originally trained in microbiology
and biochemistry, Howard was doing independent research in antibiotic
resistance and working in a clinical laboratory while in high school. He
confesses that, for his 10th birthday, he asked his mother for a copy of the
Merck Index of Chemicals and Drugs. Subsequently, he built the first clinical
computer system for Georgetown University Hospital,
developed virological systems for Electronucleonics’ “hot lab” and developed
cardiac care simulators and for the George Washington University School of Medicine,
Office of Computer-Assisted Instruction. He also developed the first automated blood
bank laboratory tools for the Red Cross.


Full disclosure—he has two patents in process for hospital communications and staff management dedicated to keeping them informed, in real time, of patient needs.
His post follows below.

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