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“Closing the Gap: Implementing Solutions to Health Care Disparities in New York”Daniel Laroche MDPresident, Empire State Medical Association,NYS National Medical Association affiliateAssistant Professor OphthalmologyNew York Medical CollegeNew York Eye and Ear InfirmaryPresident, Advanced Eyecare of New York
1870: The integrated National Medical Society delegation was excluded from the AMA Annual Meeting in Washington, D.C.
1874: The AMA adopts a system of governance allowing state medical societies to determine which local societies will be recognized at AMA meetings, effectively allowing each state to decide the question of racial segregation.
1910: The AMA-requested Flexner Report, Medical Education in the United States and Canada, is published; the report recommends that all but two black medical schools be shut down.
1939: The AMA discontinues its policy of listing black physicians as "colored" in its American Medical Directory. The House of Delegates adopts policy discouraging racial discrimination in constituent society membership but allows it to continue.
1965-1968: The National Medical Assn. and the Medical Committee for Human Rights picket the AMA's meetings, protesting the Association's lack of action on state and county medical societies' racial exclusion policies.
The American Medical Association officially apologized in July for its history of excluding black physicians from membership, for listing black doctors as "colored" in its national physician directory for decades, and for failing to speak against federal funding of segregated hospitals and in favor of civil rights legislation.
"The AMA failed, across the span of a century, to live up to the high standards that define the noble profession of medicine," said AMA Immediate Past President Ron Davis, MD,
Journal of the American Medical Association.
July 2007 Hawaii
July 2008 Atlanta
The number of Black physicians has not increasedsubstantially over the past decade and remains far less than
their corresponding proportion in the state’s population. Black physicians are more likely to practice in a primary care specialty and work in hospitals and clinics. They are alsomore likely work in areas of the state that are federally designated as primary care shortage areas.
Black physicians, improve the diversity and cultural
competency of the physician workforce, can increase access
to care and quality of care for underserved populations in New York
Source: NYS Education Department Physician Re-licensure SurveyThe Center for Health Workforce Studieshttp://chws.albany.edu
Died of liver cancer
At age 57
Breast Cancer Stamp
In 2005 the costs of an additional
3,100 hospitalizations in the
bottom two sixths neighborhoods
was $37 million. Much of it paid by
the public through Medicaid or
hospital charity pool.
New York City Department of Health and Mental Hygiene
Rap star Coolio suffers from
Asthma and is a spokesperson
For the Asthma and Allergy
Kirby Puckett had to
Retire early from
Baseball and loss vision
In one eye from
Ray Charles went
Blind from glaucoma
At age 6
Surgical Undertreatment of Glaucoma in Black Beneficiaries of
Medicare: Archives of Ophthalmology Vol 118, Feb 2000
WK Kellogg Foundation, CDC
71.8 years for African Americans 77.4 years for Whites
Between 1990 and 2001, black men’s life expectancy increased by nine years and black women increased by 5 years. Whites increased too by ½ as much
The Funding Gap: Low- Income and Minority Students Receive Fewer Dollars by the Educational Trust 2002
Marian E. Gornick, M.S., Paul W. Eggers, Ph.D., Thomas W. Reilly, Ph.D., Renee M. Mentnech, M.S., Leslye K. Fitterman, Ph.D., Lawrence E. Kucken, M.P.A., and Bruce C. Vladeck, Ph.D. NEJM Vol 335:791-799, No. 11, 8/12/96
HHC President Alan D. Aviles said in a statement "It is clear that some of our employees failed to act based on our compassionate standards of care."
NYCLU Executive Director Donna Lieberman said at the time "The pattern of neglect and abuse at Kings County Hospital Center is an affront to human dignity,".
“There over 80,000 black patients like Esmin Green that die prematurely every year across the US due to healthcare disparities and lack of cultural competency.“
How many more deaths will be needed to enact statewide healthcare reform?
In 2004 there were 74 primary care physicians per 100,000 people in the bottom sixth neighborhoods of health outcomes
This is compared to 197 primary care physicians per 100,000 people in the top sixth neighborhoods of health outcomes.
We must all respect each other to prevent the atrocities and excess deaths from racism and discrimination
Improve educational protocols in the zip codes with the highest health disparities: Rationale: Schools like the Harlem Village Academy Charter School should be a model for all NYC public school education. They have taken 5th graders performing in the bottom 25% of test scores and turn them around by the time they enter 7th grade to be in the top 5% of test scores city wide. They have a rigorous curriculum grounded in the highest expectations for all students. A caring and nurturing environment. They teach students to think deeply, independently, and critically. They have a longer school day from 7:30 am to 5:30pm with Saturday school and study hall for students whom need extra help and attention. They have a culture of accountability for academic achievement, a clear strict code of conduct that is consistent throughout the school and school uniforms that contribute to a culture of respect, scholarship, and community.
“US Labor Department, June 2004”
Improve the self-esteem of Black youth and educate all youth about the truthful significant historical contributions by Blacks to society today. The current educational system fails to teach the truth about history specifically the original contributions to civilization, science and technology by Africans via Ethiopia, Egypt, the Black Pharaohs contributions by the building of the pyramids. The first great physician Imhotep was an African physician. The teaching of the accomplishments of Blacks both ancient and modern in the New York City public school system would improve the self-esteem to Blacks to achieve and strive to become the future Black or American Heroes.
*Support Reading Programs
Encourage all students to carry a book and read 1-2 hours a day.
Stop the notion in the Black community that reading is acting white, this is a concept that is still prevalent from slavery in many black communities.
Support Mentoring programs
Support educational summer programs and afterschool programs
There is racial bias at every stage of the criminal justice system including policing, arrests, sentencing and parole.
In Suffolk County Blacks make up 7% of the population but 40% of the jail population.
In Rensselaer County Blacks make up 5% of the population but 35% of the jail population.
We MUST STOP DISCRIMINATION, The statistics are not a result of more criminal behavior in the Black community
We must Stop the State Commission of Corrections from mandating the construction of correctional facilities in NYS
We must institute contract controls to monitor how contracts are distributed and their impacts on taxpayers
Established 10 years ago Divert Court has been shown to have a tremendous cost/benefit savings.
On average, for every $1 spent on upgrading drug treatment and diverting offenders from traditional incarceration, to drug treatment through DIVERT Court, $9.43 of costs can be saved by society over a 40 month post-treatment period.
Emphasis is place on rehab and treatment and avoiding incarceration
WHAT A RETURN ON INVESTMENT!!!!!!!
Creating Pre-Arrest Programs, Citation programs to avoid initial booking
Programs for the mentally ill
Improve release procedures and the pretrial and sentenced populations
Specialty courts, drug court, mental health court, domestic violence court
Alternative punishment to incarceration including expanding probation
All suggestions will save NYS taxpayer millions of dollars
Create violence reduction, conflict resolution, and preventive law education protocols for junior high school students and public: Rationale: This will help reduce prevent incarceration. The state does not allow religion to be taught in schools. Thus there is a void in the teaching of morals and principles of right and wrong. Children coming from poorer families often have parents away from the home working 2 and 3 jobs to make ends meet and maybe deprived of this nurturing. The educational system must participate in educating students about the consequences of criminal activity.
We must also have funding for research identifying the most common zip codes with incarcerated minority youth, and identifying the reasons for incarceration and create programs to prevent this adverse outcome in those specific zip codes.
NYC Department of Health and Mental Hygiene
Legislation must be enacted to ensure Mandatory Cultural Competency for all Physicians and Healthcare Workers in New York State. All licensed healthcare workers in New York must be made aware of the terminal effects of prejudice in healthcare on ethnic minority groups in New York State. David Satcher M.D. the former U.S. Surgeon General estimates there are over 83,570 annual premature deaths due to prejudice in healthcare. Dr. Nelson Adams the 111th President of the National Medical Association states: "Cultural competency education is urgently needed, racial inequities in healthcare will never be scientifically justified, politically excusable, and never morally acceptable".
Eliminate Health maintenance organizations: Rationale: Health maintenance organizations are a middle man in medicine. They deliver no health care and have the best interests of the their investors, shareholders, and executive compensation. Recently the CEO of United Healthcare Dr. McGuire earned 1.6 billion dollars in stock options. Instead of this money being invested for infrastructure in healthcare it is being used for personal use. Legislation must be passed to make healthcare a basic human right and not a privilege.
There are over 2 million New Yorkers without health insurance. The concepts of referral use and capitation by HMO’s only discourage the physician patient encounter delaying health care decreasing access to health care.
This has led to many hospitals closing in New York and physicians closing their offices. In New York hospitals lose approximately $750 million dollars annually and the HMO’s profit over 750 million dollars. Getting rid of HMO’s and centralizing care to a few would reduce the amount of money spent on administration and allow patients, and hospitals to thrive. More patients would also be able to obtain insurance with the expansion of the Medicaid, Child health plus program, Health NY program and Medicare program to insure all New Yorkers.
Black employees at the Department of Health are sorely underrepresented, <2 %
Black employees at the department of health are tracked into locations where the pathways to promotion have been eliminated.
NYS DOH must include health disparities in all efforts addressing healthcare for New Yorkers.
Current NYS DOH organizational infrastructure encourages and perpetuates unequal promotion, unequal distribution of resources further exacerbating healthcare disparities.
Must expose and eliminate deeply embedded pathways, procedures and practices that foster unequal geography of institutional opportunity.
Increase the ability of Blacks and Latinos to build and maintain knowledge and leadership capital, maximize growth potential, and be promoted within the department of health.
Bring the Office of Minority Health from the fringe to the core of the public health system
Relocate the Office of Minority Health to the Office of the Commissioner of Health
Increase funding to the NYS Office of Minority Health, recently its budget has been decreasing from >1 million dollars to $693,000.
Articulate a clear vision and a comprehensive plan with performance measures towards eliminating health care disparities.
Issue an Executive Order to require that each state agency shall make eliminating inequities part of its mission by identifying and addressing as appropriate, disproportionately high and adverse human health and environmental effects of its programs, policies and activities on minority populations and low income populations in New York State.
Encourage the Attorney General’s Office to challenge systematic inequities in the health care system including public health.
These companies advertise heavily in Black and Latino communities in NYC leading to increased disease and disparities in Southeast Queens, Central Brooklyn, South Bronx and Harlem. Banning these ads will help stop the glamorization of these destructive products.
The smoking ban in public places has worked well to reduce the number of new smokers.
Create and enhance preventive public service announcements.
Educational advertisements regarding diet, exercise, substance abuse, smoking, sexually transmitted diseases will help prevent premature death from cardiovascular disease, cancer, homicide, HIV .
Educational announcements of reducing asthma by reducing air pollution and household mold.
Advertisements via radio, television, billboard posters and press conferences are very effective toward educating the public about the latest health alerts, issues and action initiatives.
Repeal the New York Medicaid cuts for healthcare for those patients with dual Eligibility with Medicare: These cut backs have reduced patient’s access to private physicians in poorer and underserved neighborhoods.
The cutbacks also discourages physicians from setting up practices in poor communities since they will be receiving less reimbursement than physicians whom practice in wealthier communities.
Physicians that open up their primary practices, (>50% time) in poorer underserved neighborhoods in designated zip codes in central Brooklyn, Southeast Queens, South Bronx, and Harlem, should also receive special state and city income tax and property tax breaks to offset student loans and lower income received from serving these communities and receive increased reimbursement.
Tort reform with caps on malpractice awards. This will ensure more funds available for healthcare instead of trial lawyers that on many occasions file frivolous lawsuits costing healthcare providers millions of dollars depleting monies for healthcare.
Ob-Gyn Malpractice insurance in NY ranges from $150,000 to $250,000.
7 counties in NYS do not
have an Ob-Gyn as a result of this.
The average medical liability award has gone up 35% to $8,134,102.
The civil justice system frequently produces awards where there has been no negligence
In many cases where there has been negligence the system often produces no payments to the plaintiff
Physicians are now increasingly being forced to view their patients as potential plaintiffs rather then person in need of care
Over the past 10 years MLMIC has spent of $500 million to defense physicians and hospitals on whose behalf no payment was ever paid to the plaintiff that filed a claim.
In NY 71% of Neurosurgeons have been sued
In NY 67% of Ob-Gyns have been sued
No other level of human activity is the source of such lawsuits
Many hospitals have close their OB-Gyn divisions
Special health courts
No-fault system for claims involving neurologically impaired infants and emergency department care.
Most neurological conditions involve impairment prior to birth.
Tightening of rules of whom can be an expert witness in a medical liability action.
Disclosure of the identity of an expert witness in a medical liability action prior to trial.
Expert witnesses must be practicing the same specialty as the physician whom against whom the lawsuit if filed.
$250,000 cap on non-economic damage awards.
State-funded subsidy and/or tax credit to defray the cost of medical liability insurance.
Create a “clear and convincing” standard of proof in medical liability actions, a higher standard than the current “preponderance of the evidence standard”
Impose a $10,000 fine on an attorney who brings frivolous action and enforce the penalty
Immunity for Apology- 27 states have and “I’m sorry Law” to protect health care providers who express sympathy to a patient for an unanticipated outcome from having such a statement used against the health care provider in any subsequent litigation that may arise.
50% discount on malpractice premium for those physicians that practice in zip codes affected by the highest healthcare disparities
Contact all local New York Medical Schools and Hospitals to immediately enforce nondiscriminatory laws by recruiting underrepresented Black and Hispanic physicians, medical students and health personnel: Currently New York City is 60% Black and Hispanic. The number of Black and Hispanics in New York Medical Schools are 5%. The leadership in both medical schools and hospitals has failed to diversify and support the medical staff to address current healthcare disparities.
Reduce the cost of medical education.
In some areas of NY as much as 51% of Black men in are unemployed.
Immediately develop job-training programs: Unemployment leads to poverty, substance abuse, and crime. Not only are the men affected but also the women and children of the family.
Globally Drug companies make 50% of their profits off of the American consumer alone. Pharmaceutical cost reduction protocols such as those used in Canada and other countries will reduce the cost the medications particularly for patients whom are poor and may not be able to afford them to reduce health disparities.
Legislation must be considered to reduce the mark up of medications.
Parallel importation of drugs will stimulate free enterprise and reduce the costs of medications as is seen in Europe.
Patients need to see physicians in a “medical home” at their doctor’s office, not a drug store clinic that bombards them with unhealthy candy, chips, soda and food as you enter the drug store.
Doctor don’t spend 8-15 years of their life training to work out of a retail drug store.
Areas most in need: codes in New York that are clearly known to have these disparities in health, education, and unemployment. Specifically Central Brooklyn, Uptown Manhattan, South Bronx, Southeast Queens.
Harlem, So. Bronx, Central Brooklyn