HEALTH AND HEALTH CARE DISPARITIES

SEMINOLE COUNTY MEDICAL SOCIETY

MARILYN HUGHES GASTON, MD

MAY 23, 2006

“NO AREA OF INJUSTICE AND SHAME IS AS GREAT

AS IN THE AREA OF HEALTH”

MARTIN LUTHER KING, JR.

U.S. HEALTH OUTCOMES

• LIFE EXPECTANCY – 19TH AND 25TH IN WORLD (1900 B/W DISPARITY 15 YEARS)

• PREMATURE & PREVENTABLE DEATHS• EPIDEMICS OF CHRONIC ILLNESS –

OBESITY AND DIABETES• DISPARITIES BETWEEN POOR & NON-

POOR, RACE / ETHNICITY, GENDER, GEOGRAPHY

HEALTH OUTCOMES (CONT)

• SOME IMPROVING – HEART DISEASE, CANCER, STROKE, SMOKING

• IMPROVEMENT IN SELF-CARE• OTHERS GETTING WORSE – ASTHMA,

DIABETES, MENTAL HEALTH (STRESS, DEPRESSION), OBESITY

DEATH RATE /100,000 ALL CAUSES

MEN AND WOMEN

0100

200300

400500

600700

800900

1000

MEN WOMEN

WHITEAF.AMER.AI/ANASIAN/PILATINO

AGE ADJUSTED DEATHS/100,000

WOMEN

0

20

40

60

80

100

120

140

160

HEART CANCER STROKE

WHITEAF.AMER.AI/ANASIAN/PILATINO

AGE ADJUSTED DEATHS/100,000

MEN

0

50

100

150

200

250

HEART CANCER STROKE

WHITEAF.AMER.AI/ANASIAN/PILATINO

DEATH RATES HEART DISEASEFLORIDA & U.S.WOMEN - 2002

0

50

100

150

200

250

300

FLORIDA U.S.

WHITE

BLACK

AMIND

API

HISPANIC

DEATH RATE HEART DISEASEFLORIDA & US

MEN - 2002

0

50

100

150

200

250

300

350

400

FLORIDA US

WHITE

AF AM

AMIND

API

HISPANIC

CANCER DEATHS/100,000BY RACE/ETHNICITY

0

5

10

15

20

25

30

35

40

45

LUNG COLOREC PROST. BREAST

WHITEAF.AMER.AI/ANASIAN/APLATINO

Source: Mokdad et al., Diabetes Care 2000;23:1278-83.

Diabetes Trends* Among Adults in the U.S.,

(Includes Gestational Diabetes) BRFSS 1990

Diabetes Trends* Among Adults in the U.S.,

(Includes Gestational Diabetes) BRFSS 1993-94

Source: Mokdad et al., Diabetes Care 2000;23:1278-83.

DNPA Graphics:

DNPA Graphics:DNPA

Graphics:

DNPA Graphics:

Diabetes Trends* Among Adults in the U.S.,

(Includes Gestational Diabetes) BRFSS 1999

Source: Mokdad et al., Diabetes Care 2001;24:412.

DNPA Graphics:

DNPA Graphics:DNPA

Graphics:

DNPA Graphics:

Diabetes Trends* Among Adults in the U.S.,

(Includes Gestational Diabetes) BRFSS 2001

Source: Mokdad et al., J Am Med Assoc 2001;286:10.

DIABETES DEATH RATESWOMEN - 2002

0

10

20

30

40

50

60

FLORIDA US

WHITE

AF AM

AMIND

API

HISPANIC

DIABETES DEATH RATESMEN - 2002

0

5

10

15

20

25

30

35

40

45

50

FLORIDA US 4th Qtr

WHITE

AF AM

AMIND

API

HISPANIC

Negative Mood by Gender and RaceNegative Mood by Gender and Race

CaucasianMen5.8

CaucasianWomen

8.1

AfricanAmerican

Men10.9

AfricanAmericanWomen

16.4

FACTORS INFLUENCING THESE OUTCOMES

POPULATION LEVEL:

• BARRIERS TO ACCESS TO CARE• BROKEN HEALTH CARE SYSTEM QUALITY - UNEQUAL TREATMENT• SOCIOECONOMIC/ CULTURAL AND

LANGUAGE ASPECTS

FACTORS INFLUENCING THESE OUTCOMES (CONT)

INDIVIDUAL LEVEL:

• LIFESTYLE• GENETICS• EDUCATIONAL• LOW HEALTH LITERACY• ATTITUDINAL

ACCESS

• TO QUALITY CARE FOR EVERYONE

• TO AFFORDABLE MEDICATIONS

• TO MEDICAL INFORMATION

• FINANCIAL• GEOGRAPHIC/CAPACITY• CULTURAL/LINGUISTIC• ATTITUDINAL• EDUCATIONAL – HEALTH

LITERACY• VULNERABLE POPULATIONS• SYSTEMS OF CARE

Barriers to CareBarriers to Care

FINANCIAL BARRIERS

• POVERTY

• UNINSURED – 45 MILLION

FOR ENTIRE YEAR

• 70 MILLION UNINSURED FOR PART OF YEAR

• UNDERINSURED – MILLIONS

• 5TH LEADING CAUSE OF DEATH(IOM)

No Physician ContactIn Past Year With a ProblemNo Physician ContactIn Past Year With a Problem

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Poor Middle High

Hispanic

African/American

White

%TOTAL UNINSURED 2004

0

5

10

15

20

25

30

35

40

45

FLORIDA US

WHITE

AF AM

HISPANIC

Uninsured and MinoritiesUninsured and Minorities

Hispanics35%

African/Americans25%

Asian20%

White12%

Percent of US Under Age 65 Who Say in Past 12 Months They Have . . .Percent of US Under Age 65 Who Say in Past 12 Months They Have . . .

0

10

20

30

40

50

60

70

80

RoutinePhysical Exam

Pap Smear Mammogram ProstateExam

Source: Kaiser Family Foundation National Survey on the Uninsured, April 2000

70 76 40 2047 49 16 12

Insured

Uninsured

INSURANCE & STAGE OF DISEASE AT DIAGNOSIS OF BREAST CANCER

0

5

10

15

20

25

30

35

40

45

I II A II B III IV

UNINSUREDINSURED

Physicians who treat Medicaid or Uninsured PatientsPhysicians who treat Medicaid or Uninsured Patients

Hispanics33%

African/Americans48%

Asian34%

White24%

NATL. HEALTHCARE DISPARITIES REPORT

• ACCESS MEASURES - 31

• AA – WORSE ON 40%

• LATINOS – WORSE 90%

• AIAN – 50%

• API – 30%

• POOR PEOPLE – 80%

Health Professional ShortagesHealth Professional Shortages

0

500

1000

1500

2000

2500

3000

1990 1992 1994 1996 1998 2000

Rural

Urban

BROKEN HEALTH CARE SYSTEM

• NON-SYSTEM – NOT COORDINATED, IS FRAGMENTED

• QUALITY OF CARE NEEDS IMPROVING

• DISCRIMINATION, BIAS, PREJUDICE

• FOCUSED ON TREATMENT – NOT

PREVENTION

• TOO FEW MINORITY PROVIDERS

How We Have to Change Our Health Care System!How We Have to Change Our Health Care System!

Tertiary Care

SecondaryCare

PrimaryCare

Tertiary Care

SecondaryCare

PrimaryCare

100%/0 is the movement where communities are flipping the pyramid!

HospitalEmergency Room

SpecialtyCare

Social Service #1

Primary Care Clinics

Other

Social Service #2

Social Services #3 - #20

HospitalCare

Unmanaged Patient Flow Uncoordinated

Low Quality

Service Gaps Dysfunctional

Fragmented

Costly

Emergency Room At the Center of the “System”

Program “Stovepipes”

HealthDepartment

Current Situation for the Underserved in Many Communities

Current Situation for the Underserved in Many Communities

QUALITY OF CARE

• INSTITUTE OF MEDICINE (IOM) REPORT –CROSSING THE QUALITY CHASM

• WORLD HEALTH ORGANIZATION (WHO) REPORT

• PATIENT SATISFACTION NOT GOOD• “UNEQUAL TREATMENT”

UNEQUAL TREATMENT

• IOM REPORT• DISPARITIES IN HEALTH CARE PRESENT

AND UNQUESTIONED• WITH ELIMINATION OF SES DIFFERENCES

AND ACCESS DISPARITIES STILL REMAIN• EVIDENCE OF BIAS, PREJUDICE AND

DECISIONS INFLUENCED BY PATIENTS’ RACE AND ETHNICITY.

QUALITY OF CARE (CONT)

• INFORMATION EXPLOSION

• EXPLOSION IN NEW CLINICAL TECHNOLOGIES

• INCREASING CONSUMER DEMAND AND INCREASING LITIGATION

• INCREASING DATA WITHOUT EXPLOSION IN INFORMATION TECHNOLOGY

The Institute of MedicineThe Institute of Medicine

“Between the health care we have and the care we could have lies not just a gap,

but a chasm.” To fill that chasm requires we work together to

“redesign health care processes”

Crossing the Quality Chasm, A New Health System for the 21st CenturyIOM March, 2001

Care Should Be:

• Safe• Effective• Patient-Centered• Timely• Efficient• Equitable

The Institute of MedicineCrossing the Quality Chasm

The Institute of MedicineCrossing the Quality Chasm

NATL. HEALTH CARE DISPARITIES REPORT

• QUALITY MEASURES – 38

• AA – POORER QUALITY 66%

• LATINOS – 50%

• AIAN – 30%

• ASIANS – 10%

• POOR PEOPLE – 60%

SOLUTIONS

Primary Care Centered Community Health System: Primary Care Centered Community Health System:

Hospital

SpecialtyCare

Social Services

Primary Primary Care and PreventionCare and Prevention

IntegrativeReferralSystem

Other

Case Management of Chronic Conditions

Insurance Partnerships

Medical Homes

Disease Management

Disparity Elimination Campaigns

“Share The Savings” Plans

Organized Pharmacy

Common Sliding Fee Scales

Outreach & Common Enrollment

Automated Appointment Systems

Guiding Coalition, Collaborative

Patients in Primary Care Medical Homes

Specialty Referralfor Uninsured

InformationSystems

Guiding Coalition

100% Access System

TranslationOutreach

EnrollmentTransportation

Health Education

HospitalServicesCore Services

• preventive• primary care• oral health• lab & x-ray• pharmacy• primary mental health

SpecialtyCare

Mental Health

CommunitySocial Services

Clinics

NHSCHospitals

AHEC Universities

VoluntaryHealth

Association

LocalGovernment

School-basedPrograms

Maternal & ChildHealth Programs

Faith-basedPrograms

Public HealthDepartment

CommunityDevelopmentPartnerships

Comprehensive Primary Care and Prevention

Veterans Administration

Ryan WhitePrograms

Health CentersFQHC

SubstanceAbuse

Case-Managed,Integrative

ReferralSystem

Complementaryand Alternative

Therapies

EnvironmentalHealth

Medical Society

Foundations

Unions

Primary Care Centered Community Health SystemPrimary Care Centered Community Health System

Galveston, Texas Primary CareCentered Health SystemGalveston, Texas Primary CareCentered Health System

Galveston’s 100% Access System

Comprehensive Primary Care and Prevention

St. Vincent’s Episcopal House & Clinic

SocialServices

ReligiousMinistries

MedicalServices St. Agustine of Hippa Episcopal

Moody Memorial Methodist First Presbyterian St. Patrick Catholic Holy Rosary Shilo AME Temple B’nai Israel University Baptist Trinity EpiscopalUnitarian Universalist Fellowship

TX Dept. HumanServices

Salvation Army

Catholic Charities

Community Action Council

University of Texas Medical Branch

Galveston CountyHealth District

Case-Managed, Integrative Referral SystemTranslation

Outreach

Enrollment

Transportation

Health Education

Core Services

•Preventive•Primary care•Dental•Lab & Radiology•Pharmacy•Primary Mental Health

Complementaryand Alternative

Therapies

Hospital

Services

Specialty

Care

Substance

AbuseMental

HealthSCAN

Southeast CostalArea Network

InformationSystems

GuidingCoalition

CommunityDevelopmentPartnerships

Employment-Gulf Coast Career Ctr

Areas Health Education Centers

Universities

Medical Society

VeteransAdministration

EnvironmentalHealth

Businesses

FreeClinics

Voluntary HealthAssociation

Local Government

School-based Programs

Legal – Gulf Coast Legal Foundation

Accessibility/Disability Services

National Health Service Corps

Federally QualifiedHealth Centers

Hospital

Nutrition Services

Public HealthDepartment

Foundations

Federal EntitlementPrograms

EmpowermentZones/EnterpriseCommunities

Faith-based Programs

Senior Citizens Programs

Maternal & Child Health Programs

Ryan White Programs ACCT- The AIDS coalition of Coastal TX Children's Health Insurance Program CHIP

Jesse Tree

Immunization CoalitionMainland Medical Center

Galveston County Social Services

4Cs Health Center

Better Health

for More People

for Less Cost

Better Health

for More People

for Less Cost

Models: Community Health CentersModels: Community Health Centers

• Community-owned boards• Address all barriers• 85% Poor and near-poor• 70% Minority• 41% Uninsured• 33% Medicaid

Unmet Healthcare Needs Among Uninsured PersonsUnmet Healthcare Needs Among Uninsured Persons

0

10

20

30

40

50

60

Did not get medical care

Delayed seeking care due to cost

Did not fill prescription

Sources: Kaiser Family Foundation/Commonwealth Fund, National Survey of Health Insurance

U.S. Uninsured

CHC Uninsured

Health center uninsured patients report unmet needs at half the National rates.

30 55 2416 25 12

Percent

Health Promotion TopicsHealth Promotion Topics

0

10

20

30

40

50

60

70

80

Diet Activity Smoking Alcohol Drugs SDTDs

Source: Health Center User Survey; NHIS 1995

Uninsured Adults

54 43 57 49 75 64 68 53 55 39 54 36

CHC

U.S.

Prevention – Woman Receiving MammogramsPrevention – Woman Receiving Mammograms

0 20 40 60 80

All women

<100 Poverty

100-200 Poverty

African American

Hispanic

White

Source: Health Center User Survey, NHIS and HP 2010 Contact: Bob Politzer, ScDEmail: RPOLITZER@HRSA.GOV

62.2 %

59.7 %

61.6 %

76.7 %

58.4 %

44.5 %

40.2 %

46.7 %

49.6 %

48 %

44.5 %

63 %

2010 ObjectiveHealthy People

Health Centers Comparison Group

Significantly Lower Odds of Being Hospitalized For An Ambulatory Care Sensitive Condition

Medicaid Health Center Users . . .Medicaid Health Center Users . . .

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Source: Falik et al. ACSC Hospitalization and ER visits; 2001

Medicaid CHC Users

Medicaid Non-CHC Users

.78

1

Od

ds

Rat

io

Using Health Centers are Three Times as Likely to ReportBlood Pressure Under Control as NHIS Comparison Group

African American & Hispanic HypertensivesAfrican American & Hispanic Hypertensives

0

0.5

1

1.5

2

2.5

3

3.5

Source: NHIS & CHC User Survey, 1995 Method: Personal interviews with representative sample of health center users; comparison group from NHIS respondents w/ similar income who had at least 1 physician visit

Medicaid CHC Users

Medicaid Non-CHC Users

3.3

1

Od

ds

Rat

io

Source: C Hupke, IHI, Chupke@nibcomp.com

7.5

8

8.5

9

9.5

10

Ap

r-99

May

-99

Jun

-99

Jul-

99

Au

g-9

9

Sep

-99

Oct

-99

No

v-99

Dec

-99

Jan

-00

Feb

-00

Mar

-00

Ap

r-00

May

-00

Jun

-00

Jul-

00

Au

g-0

0

Sep

-00

Oct

-00

No

v-00

Dec

-00

Jan

-01

Feb

-01

Mar

-01

Ap

r-01

May

-01

Jun

-01

Jul-

01

Ave

rag

eAverage HbA1c for Health Centersin (Southeast Cluster), 1999-2001

Average HbA1c for Health Centersin (Southeast Cluster), 1999-2001

Month

Sources: Uniform Data System, BPHC/HRSA 1998; Health, United States, 1998, NCHS/CDC, 1998 (1996 data).

Reducing Low Birth Weight RatesReducing Low Birth Weight Rates

All HC Infants

All U.S. Infants

African American HC Infants

African American U.S. Infants

7.1 %

7.1 %

13 %

9.9 %

BLACK/WHITE DEATH RATE BY HC PENETRATION

0

50

100

150

200

250

300

<10% 10-20% >20%

Eliminating Early Breast Cancer Detection DisparitiesEliminating Early Breast Cancer Detection Disparities

Contra Costa County, California

Percent ofBreastCancer

Detected at Stage 1

0

44

72

100

73

58

71 %70 %

77 %Asian/PI

Caucasian

Latina

African American

SolutionsSolutions

• System level change• Address barriers• Community involvement• Training – Cultural competence – Increase

minorities• Improve Quality• Replicate Models

QUALITY SOLUTIONS

• TRANSFORM PRACTICES-CHRONIC DISEASE MANAGEMENT

• INCREASE CULTURAL & LINGUISTIC SKILLS• ENHANCE PATIENT-PROVIDER

COMMUNICATION-HEALTH LITERACY• INCREASING PATIENT EDUCATION AND

SELF-CARE• MONITOR BIAS & DISCRIMINATION• INCREASE TRUST

1 2 3 6 754

5ccs

Which is a teaspoon?

/

1 2 3 6 754

5ccs

ccs. 5 8 4 4.5 5 3.7 4.3

QUALITY SOLUTIONS (CONT)

• EFFECTIVE EVIDENCE BASED INTERVENTIONS

• FOCUS MORE ON PREVENTION• INCREASE COMMUNITY INPUT• INCREASE MINORITY PROVIDERS• MAKE CARE MORE HOLISTIC (MIND,

BODY, & SPIRIT)• INTEGRATE MENTAL HEALTH

SERVICES

IOM CLOSING THE GAP REPORTS

• Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care 2002

• Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 2003

• Emerging Issues in Hispanic Health 2002• The Right Thing to Do, The Smart Thing to Do:

Enhancing Diversity in Health Professions 2001• Coverage Matters: Insurance and Health- 5 Vol.• America’s Health Care Safety Net:Intact But

Endangered 2001

DIFFERENCES IN RISK FACTORS

0%

10%

20%

30%

40%

50%

60%

SMOKER INACTIVE OBESE

AAWHITE HIS/LATAIANAAPI