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Healthcare Disparities

National Haitian American Health Alliance 6 th Annual National Conference. Rubens J. Pamies, M.D., FACP Vice Chancellor Academic Affairs Dean of Graduate Studies / Professor of Internal Medicine University of Nebraska Medical Center. Crisis in Medicine for the 21 st Century.

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Healthcare Disparities

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  1. National Haitian American Health Alliance 6th Annual National Conference Rubens J. Pamies, M.D., FACP Vice Chancellor Academic Affairs Dean of Graduate Studies / Professor of Internal Medicine University of Nebraska Medical Center Crisis in Medicine for the 21st Century Healthcare Disparities Brooklyn Borough Hall October 9, 2009

  2. Where is Nebraska?

  3. Rural Nebraska

  4. Downtown Omaha, Nebraska

  5. Nebraska Football

  6. The major issues facing health care: • Workforce • Cost of Health Care • Insurance Coverage • Quality • Disaster Planning And… Health Care Disparities

  7. Workforce • 1/3 of new jobs will be in health care • Maldistribution • Globalization • Aging of health care provider • Gender issues • Shortage of health care providers

  8. Cost of Health Care • Up to 25% of GNP • Transparency • “Concierge medicine” • Malpractice • Regulatory affairs • Aging of the population

  9. Driver of High Cost in Healthcare • High Administrative Cost • Medical Errors • Nosocomial Infection • Managing Chronic Disease • Overutilization • Under-utilization

  10. Chronic Diseases Account for 80% of Health Care Spending The Major Factors include:

  11. Insurance Coverage

  12. Lack of health insurance for children 2001

  13. Quality • Medical errors • Pay for performance • Cultural competency • Value based purchasing • Patient Education

  14. Patient Education • Only 8% Knew the warning signs of Glaucoma • Only 51% Knew the link between Diabetes and eye disease • Only 16% has heard of the condition “Low Vision” • 50% of Diabetic patients do not receive appropriate eye treatment

  15. Disaster Planning • Katrina • 9/11 • SARS • bioterrorism

  16. Disparities in Health Care • Includes all to these issues • Social conditions which determines health outcomes adds significantly to disparities in health That’s why: • Solving the problem of health disparity will be the most difficult challenges facing academic health centers

  17. The Long and Winding Road of Health Reform Starting with Teddy Roosevelt • Franklin Roosevelt and Social Security • Harry Truman and fear of socialism • Lyndon Johnson and Medicare/Medicaid • Richard Nixon loses Wilbur Mills to scandal • Jimmy Carter tries to start with children • George H.W. Bush and tax credits as a starter • Bill Clinton and the Health Security Act (first time committees reported out) • ???

  18. Cooperation Coordination Collaboration Cooperation Coordination Collaboration

  19. Motivation to Change • 47 million or more uninsured: “core” far exceeds the 7 million sometimes touted • Ever increasing expenditures crowding out other uses of resources • Ever increasing health insurance premiums contributing to cost of labor • Changes in health insurance coverage increasing personal expenditures • Aggregate data and real life stories • 45,000 die each year from being uninsured

  20. In the Legislative Process Now, Something Akin to Bracketology

  21. International Comparison of Spending on Health, 1980-2006 Total expenditures on healthas percent of GDP Average spending on healthper capita ($US PPP) Data: OECD Health Data 2008 (June 2008).

  22. a a b a Percentage of National Health Expenditures Spent on Insurance Administration, 2005 Net costs of health insurance administration as percent of national health expenditures a 2004 b1999 - * Includes claims administration, underwriting, marketing, profits, and other administrative costs; based on premiums minus claims expenses for private insurance. Data: OECD Health Data 2007, Version 10/2007. Source: Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008 (New York: The Commonwealth Fund, July 2008).

  23. Hospital Discharges per 1,000 Population, 2006 *2005 **2004 Data: OECD Health Data 2008 (June 2008).

  24. Inpatient Hospital Spending per Capita in 2004 Adjusted for Differences in Cost of Living a b b a a2003 b2002 Source: The Commonwealth Fund, calculated from OECD Health Data 2006.

  25. The Aging Population Will Need More Health Care Services Cumulative Percent Growth in Population, by Age Group (relative to 2006) From: Dill MJ & Salsberg ES. The Complexities of Physician Supply and Demand: Projections through 2025. AAMC Center for Workforce Studies. November, 2008

  26. Annual Per Capita Total Health Expenditures by Age Group, 2008* Dollars * Inflated to 2008 dollars using actual and estimated annual growth rates in national health expenditures. Source: Analysis of the 2005 Medical Expenditure Panel Survey by S. Glied and B. Mahato for The Commonwealth Fund.

  27. Coronary Bypass Proceduresper 100,000 Population, 2006 *2005 **2004 Data: OECD Health Data 2008 (June 2008).

  28. Magnetic Resonance Imaging (MRI) Units per Million Population, 2006 *2005 **2004 Data: OECD Health Data 2008 (June 2008).

  29. Mirror, Mirror: Ranking of Six Nations * 2003 data Source: K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea, “Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care,” The Commonwealth Fund, May 2007

  30. Life Expectancy at Birth, 2006 Years *2005 Data: OECD Health Data 2008 (June 2008).

  31. Longevity (Life Expectancy) is a Measure of National Health • For all the spending and testing, life expectancy for U.S. citizens is the lowestof the industrialized countries: • 80.4 years for females, • 75.3 years for males. • For African-American U.S. citizens it is significantly lower: • 77 years for females (3.4 year difference) • 70.2 years for males (5.1 year difference) National Vital Statistics Report 47:28 2009

  32. Health Disparities for African-Americans Take a Great toll Annually 40% higher rates of heart disease 30% higher rate for ALL cancers 60% more likely to have a stroke 2.3 times greater infant mortality 1.3 times as likely to be diagnosed with lung or prostate cancer 7 times as likely to be diagnosed with HIV/AIDS 2 times as likely to be diagnosed with diabetes

  33. Future Health Care Workforce

  34. ThePhysician Output of U.S. Medical Schools Has Not Changed much Since 1980.

  35. U.S. Medical School Graduation by Race and Ethnicity: 1977-2008 Source: Diversity in Medical Education Facts and Figures 2008

  36. If Nothing Changes by 2025, then the Physician Shortage will be Enormous Dill MJ & Salsberg ES. The Complexities of Physician Supply and Demand: Projections through 2025. AAMC Center for Workforce Studies. November, 2008

  37. Why is it Important to Maintain an Adequate Primary Care Workforce?

  38. Why is it Important to Increase the Number of Minority Physicians? • Minority Physicians are more likely to: • choose primary care specialties • serve patients of their own ethnic group • serve Medicaid recipients • work in health manpower shortage areas • Predictors of providing care to the underserved are: • Being a minority • Having a strong interest in serving the underserved prior to medical school • Growing up in an underserved area Commonwealth fund report, Cooper and Powe, 2004

  39. Having Primary Care Providers Saves Money In 323 metropolitan statistical areas, having more primary care providers was associated with fewer hospital admissions and emergency department visits. • In a city with a population comparable to Omaha, increasing the proportion of PCPs from 35% to 40% would: • Reduce inpatient admissions by 2,500 per year • Estimated cost savings of $23 million per year • Reduce ED visits by 15,000 per year • Reduce operations by 2,500 per year KravetSJ et al. Health care utilization and the proportion of primary care physicians. Am J. Med 2008;121:142-148

  40. African American Health Professionals 1990 vs. 2000 Unites States Census

  41. Underrepresented Minority Matriculants to US Medical Schools 1995 & 2001 United States Census

  42. Chandra, A, “Geography and Racial Health Disparities, “ 2006

  43. Chandra, A, “Geography and Racial Health Disparities, “ 2006

  44. Factors that contributes to health disparities: 1. American Apartheid: South Africa (de Jure) in 1991 & U.S. (de facto) in 2000 Source: Massey 2004; Iceland et al. 2002; Glaeser & Vigitor 2001

  45. Segregation: Distinctive for Blacks • Blacks are more segregated than any other racial/ethnic group. • Segregation is inversely related to income for Latinos and Asians, but is high at all levels of income for blacks. • The most affluent blacks (> $50,000) are more segregated than the poorest Latinos and Asians (<$15,000). • Thus, middle class blacks live in poorer areas than whites of similar SES and poor whites live in much better neighborhoods than poor blacks. Source: Massey 2004

  46. How Segregation can Affect Health • Segregation determines SES by affecting quality of education and employment opportunities. • Segregation can create pathogenic neighborhood and housing conditions. • Conditions linked to segregation can constrain the practice of health behaviors and encourage unhealthy ones. • Segregation can adversely affect access to medical care and to high-quality care. Source: Williams & Collins, 2001

  47. Factors that contributes to health disparities:2. Access Having a Medical Home:source of usual care United States Census

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