A tale of two health care systems

Massachusetts General Hospital is perenially ranked at the top of every list of the best hospitals in the country and the world. It’s the flagship hospital for Harvard Medical School with a billion dollar research budget and over a dozen Nobel laureates. Patients fly in from all over the country to get a second opinion from esteemed MGH physicians for the most complex medical problems. It is a wonderful hospital that does a lot of good for the world.

But MGH is also emblematic of the racial stratification that’s imbedded in our health care system. The Boston Globe just published a fascinating and deeply reported article on the racial differences in health care in the city of Boston. The world famous hospitals of Harvard Medical School - MGH, Brigham and Women’s, Dana Farber Cancer Institute, Beth Israel Deaconness - take care of mostly white patients while blacks tend to go to Boston Medical Center, affiliated with Boston University.

The Globe article points to a handful of different explanations - geography, insurance hurdles, perception of bias from physicians - and paints a picture of a system that in total treats people very differently based on race.

This isn’t limited to the city of Boston

The city of Boston has a long history of racial tension, so it might be tempting to look at the Globe article and think this is a Boston-specific inequity.

I trained at NYU Langone Medical Center where my residency and fellowship were mainly split among Tisch Hospital with its Kimmel Pavilion, which comprise the main campus of NYU Langone Medical Center, and Bellevue Hospital, a public institution in New York City’s Health + Hospital system. These hospitals are separated by 3 city blocks.

These are fantastic places to train. World class physicians work at both hospitals and patients are thoughtfully cared for no matter which emergency room you end up in.

But it’s a lie to describe both places as equal. Everything from the hospital buildings to the staffing to the technologies available are different.

Nurses at NYU take care of fewer patients at any one time than nurses at Bellevue. They’re able to spend more time with each of their patients, get them medicines more quickly, and respond to issues that arise more expeditiously.

The Bellevue nurses are spread thin and despite working at full speed will often fall behind on medication administration schedules - delaying patients receiving their needed medications - because they are overextended and can’t physically be in two places at once.

Each private room in the Kimmel Pavilion has floor to ceiling windows with huge amounts of natural light, a private bathroom, and a 70 inch TV controlled by an iPad where you watch Netflix and order food from a chef designed menu.

Most of the rooms in Bellevue are shared among two people, but on each floor there are a handful of 4 person rooms. The food isn’t as high quality as NYU, the windows are smaller, the TVs are tiny, and the bathrooms are shared.

At Bellevue, you feel like a patient. At NYU, you feel like a guest.

NYU has the latest technology for every procedure that’s employed quickly without reservations if it seems that a patient may benefit - thrombectomy for acute stroke, ECMO for a crashing patient, immunotherapy for cancer patients.

Patients at Bellevue have “access” to these treatments, but it takes more effort for doctors to get these treatments for their patients, and barriers to care ultimately mean less care. [You could argue it means more judicious use of treatments, but that’s probably a conversation for another newsletter installment]

Your experience in the American healthcare system is very different based on your race

Very early in training, it becomes clear who is likely to be a “Bellevue patient” and who is likely to be an “NYU patient.”

Bellevue patients are black and brown. NYU patients are white.

Of course the racial differences aren’t enforced by decree, nor are the rules hard and fast. But there are subtle pushes that we would make. Patients without insurance admitted to NYU are always scheduled for follow up in the Bellevue clinic rather than the NYU faculty group practice.

In the American heath care system, hospitals want to recruit patients with private insurance - rather than Medicaid or Medicare - because private plans reimburse better. Because of the racial wealth gap, “private insurance” can feel like shorthand for “white race.”

There’s a telling quote in this article on NYU from Crain’s:

Truth be told, NYU Langone also benefits from a quirk of fate: having Bellevue Hospital Center right next door. The famed public institution draws most of the area's Medicaid and uninsured patients, as well as many from the city beyond. It's true that NYU Langone staffs Bellevue and loses money on that effort, since insurance reimbursements don't cover the doctors' salaries, but having a public magnet next door ensures a more profitable patient mix for NYU Langone.

The racial differences in our health care system aren’t caused by any one factor that can be tackled in isolation. They’re messy and multifactorial. Just like the racial differences in police violence. And the racial differences in criminal justice. And almost any other racial difference you can see. But recognizing the uncomfortable reality of the racial inequity in the healthcare system is really important. As Martin Luther King said, “of all the forms of inequality, injustice in health is the most shocking and inhuman.”