George Floyd’s murder last year forced many people to recognize the systemic racism that pervades American institutions, from law enforcement to health care. Even so, identifying those inequities is different than fixing them.
“I don’t believe we advance the debate much by writing yet another paper documenting the disparities we’ve known about for 20 or 30 years,” says Harvard Business School Professor Amitabh Chandra. “One more research paper that finds that minority health care is separate and unequal may be important but is substantially less important than research that proposes solutions for these long-standing disparities.”
For the past 20 years, Chandra has been examining differences in health outcomes between white and Black Americans, searching for solutions to shrink the gap. In a recent working paper published through the National Bureau of Economic Research, he proposes one such solution: helping Black patients choose better-performing hospitals.
“This is something we could change tomorrow,” says Chandra, the Henry and Allison McCance Professor of Business Administration. “Simply because the source of these disparities is structural, does not mean that we should have to wait 20 or 50 years to reduce them.”
"This is something we could change tomorrow."
The findings emerge as health care institutions are wrestling with the deep-seated effects of institutional racism. During the past year, amid a pandemic that has disproportionately affected people of color, hospital systems in New York, Chicago, and Boston pledged to confront inequities in hiring, leadership, and patient care.
‘Embedded in the fabric of this country’
Growing up in India, Chandra says, he absorbed a rosy idea of the United States—its victories in the Revolutionary War and World War II, its success in putting a man on the moon.
“Slavery was mentioned, as was the Civil War, but mostly as an unfortunate chapter in American history,” Chandra says.
When he later came to the US, however, he saw the legacy of that ugly chapter everywhere. “You could see the racism and racial disparities in employment, incarceration, educational outcomes, health care. It’s embedded in the fabric of this country.”
Those imbalances seemed particularly pronounced in health care. For example, Black people are 20 percent more likely to die from heart attacks than white people, Chandra’s paper says. Many theories have been proposed to explain the gulf, including income and educational inequality, and bias—intentional or unintentional—among doctors treating patients of color.
The new paper, Hospital Allocation and Racial Disparities in Health Care, co-written with Harvard University doctoral student Pragya Kakani and Columbia University professor Adam Sacarny, focuses on another explanation: differences in hospital quality.
Hospital care improves, but gaps persist
The researchers analyzed about 20 years of Medicare data, reflecting the experiences of 2 million patients, to look for patterns in hospital care. They focused on the mortality rates for heart attacks, an ailment that typically requires patients to seek hospital care, and where mortality is a validated measure of hospital quality.
They found that in the late 1990s, more patients died of heart attacks at hospitals in areas that had higher concentrations of Black patients, such as the South. However, over time, those geographical variances faded as more hospitals, especially those in cities with large Black communities, embraced best practice treatments. In particular, adopting beta blockers—a low-cost medication that increases the odds of surviving a heart attack—almost eliminated the regional performance differences of hospitals.
"Why are Black and white patients who live in the same ZIP code, who are both covered by Medicare and can go anywhere, being treated at different hospitals?"
Despite these broad gains, patient care gaps remained. By 2010, half of the difference in survival rates came down to the particular hospital choices of Black and white patients within the same ZIP code. Black patients were more likely to receive care at hospitals with lower survival rates.
“So now, the differences between Boston and Atlanta have disappeared,” Chandra says. “What’s left are these ZIP-code-level disparities within Boston and Atlanta. A ZIP code is a relatively small geographic area—so why are Black and white patients who live in the same ZIP code, who are both covered by Medicare and can go anywhere, being treated at different hospitals?”
Hospitals that tended to treat Black people not only had higher mortality rates, but they were less likely to prescribe life-saving beta blockers. In contrast, hospitals that drew more white patients in the same ZIP code were more likely to use beta blockers as well as sophisticated interventions, such as cardiac catheterization and bypass surgery.
Big problems with meaningful solutions
While the study couldn’t determine why Black patients ended up at lower-quality hospitals, Chandra is investigating three hypotheses:
- Ambulance crews chose the hospitals in many cases and possibly took African American patients to different hospitals than their white neighbors.
- Primary care physicians recommended these hospitals.
- Patients’ families had long histories of receiving care at these institutions, a holdover from a time when hospitals were segregated.
Raising the quality of subpar hospitals could take years, but solving these prospective problems could improve care for Black patients immediately. The Centers for Medicare and Medicaid Services could require ambulances to bring patients to higher-quality institutions in a given area, for example. Primary care physicians could also provide patients with outcome data for local hospitals, nudging them toward facilities with better track records.
Such changes could help not only heart attack patients, but also patients suffering from a wide variety of diseases, including diabetes and cancer, says Chandra. Such information could have been especially helpful earlier in the COVID-19 pandemic. Despite similar COVID-19 infection rates, Black people are almost three times more likely to be hospitalized and twice as likely to die from the resulting illness.
"We are not talking about just a small effect—big impacts are within our grasp."
“Although we don’t have as much data on the quality of COVID care, I’m quite sure there are much greater quality differences across hospitals in treating COVID than heart attacks,” he says. “In Boston, the leading academic medical centers, with a full staff of infectious disease specialists, pulmonary and critical care doctors, and virologists, probably had a much better sense of what treatments to use and when relative to smaller hospitals that are close by.”
By directing Black patients to hospitals that provide better care within their own ZIP codes, policymakers could provide instant relief to people hurt by health care inequality, says Chandra, who serves on the Congressional Budget Office’s Panel of Health Advisors.
“Too often in the racial disparities literature, we correctly identify root causes, but fall into the trap of thinking that root causes will also take a long time to solve. This kind of thinking is actively harmful for patients,” he says. “These are things that we could do tomorrow morning to meaningfully reduce the mortality of African Americans, and we are not talking about just a small effect—big impacts are within our grasp.”
About the Author
Michael Blanding is a writer based in the Boston area.
[Image: iStockphoto/Hispanolistic]
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