Urban hospital markets are more likely to segregate patients based on race, a new analysis shows.
Hospitals in metro markets tend to serve a whiter, wealthier patient mix, while others predominately serve patients of color and lower-income individuals, according to Lown Institute's analysis of Medicare claims spanning 2013 to 2018 across 3,200 hospitals. In the top 50 most inclusive hospitals, people of color made up 61% of patients on average, compared to 17% at the bottom 50 hospitals. Researchers ranked hospitals by comparing how well the demographics of a hospital's Medicare patients matched its surrounding communities.
The most inclusive and least inclusive hospitals can be blocks away from each other. Metropolitan Hospital Center is East Harlem, N.Y., is around a mile away from one of the least inclusive hospitals, Lenox Hill, in the Upper East Side. Metropolitan serves 77% people of color while Lenox Hill serves 33%.
"It is a form of segregation, to be blunt," said Dr. Vikas Saini, president of the Lown Institute, describing many markets as the tale of two hospitals. "In big cities where there was a lot more diversity, there was a real tendency for some hospitals to cater to primarily wealthier, whiter and more educated patients. That left other hospitals to take care of the poor, less educated and minority patients."
The hospital markets in Baltimore and Philadelphia were disproportionately less inclusive. Baltimore had nine of the most segregated hospitals and only two of the least segregated; Philadelphia had a 19-to-6 ratio.
The least inclusive hospitals served a patient population that had a $29,000 annual income above the market average. The most inclusive treated patients that earned nearly $27,000 less than the market average. Academic medical centers often treated patients on both ends of the spectrum.
There may be patient preferences in play that are hard to account for, said Terry Fulmer, president of the John A. Hartford Foundation, positing whether patients choose settings where doctors and nurses reflect the diversity in their neighborhoods.
"Having said that, it is unacceptable to have health systems work with populations selectively," she said. "We can begin to bridge gaps by insisting on new accountability measures that address inequity and relate to hospital quality and safety scorecards."
Racial disparity has systemic roots. Discriminatory lending practices have segregated communities. Minorities have had fewer chances to secure higher paying jobs with healthcare-related benefits.
Many hospitals have evolved to cater to certain kinds of patients and exclude others, Saini said. They would also seek patients who may generate more revenue, he said.
"They tend to focus on paying customers and those with commercial insurance, who tend to be white," Saini said. "By the time they reach 65, they've already established which doctors they would see. When you see these results, it's as good a definition of structural racism as you will see."
COVID-19 compounded those inequities. Transmission rates were higher based on the kinds of jobs people had and houses they lived in, among other social factors. Hospitals that predominantly served those patients were overwhelmed, Saini said.
"That's a threat to all of us," he said. "Hospitals with a history of serving communities of color needed refrigerator trucks to hold bodies of deceased patients, while wealthier hospitals nearby had empty beds."
Hospitals should factor these social inequities into where they open clinics, marketing campaigns, what kinds of staff and doctors they hire and financial aid guidelines, Saini said. Providers should recruit from poorer, rural and minority communities. Executives should involve community leaders and use inclusivity metrics as they structure their operating models. Regulations should incentivize a diverse patient mix.
Then, hospitals need to be held to those standards, experts said.
"You have to make some calls about how much revenue and high margins matter to you compared to the broader social mission," Saini said. "As long as there are differences in the kinds of payments hospitals expect to receive based on the kind of insurance patients have, it is tough to solve the problem."