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Why hospitals don't treat everyone equally
A business model favoring customers with well-paying health insurance makes it harder for low-income patients—many of whom are minorities—to get care at leading local hospitals.

Friday, September 11, 2020
Crain's Chicago Business
by Stephanie Goldberg

J. R Rivera heard "detonations" nearby as he went about his day in Chicago's Gage Park neighborhood. Then came the pain. He looked down to see blood oozing from a bullet hole in his thigh.

After nearly a week at Advocate Christ Medical Center in Oak Lawn, the otherwise healthy 49-year-old was eager to start physical therapy. But Rivera says doctors told him to go somewhere else for that—somewhere that takes patients who don't have health insurance. In a statement, Advocate declines to comment on his case but says, "We treat all people regardless of their ability to pay."

Amid a broadening public debate over social inequities in America, Rivera's experience illustrates disparities in medical care. Uninsured and underinsured patients like Rivera often get turned away when they seek nonemergency treatment at leading hospitals. The unequal treatment is rooted in a financial model that favors patients with well-paying private coverage. As a result, low-income patients—many of whom are minorities—find themselves excluded from many of the area's top hospitals. That can mean less access to state-of-the-art technology and world-class specialists.

"The basic fact is, not all affluent and bigger institutions accept all insurances," says Dr. Eden Takhsh, chief quality officer at St. Anthony Hospital, a safety-net hospital serving many low- and moderate-income patients on Chicago's West Side. "Our community reflects who shows up at our doorstep and, for others, their communities are different. So, our community knows not to show up at their doorstep."

Local hospitals that treat large numbers of poor and uninsured patients scored the best in a new national ranking that evaluates hospitals based on their commitment to equity, inclusion and community health. Meanwhile, hospitals owned by some of the area's largest chains, including Northwestern Medicine and Advocate Aurora Health, got lower marks from the Lown Institute, a think tank based in Brookline, Mass.

The institute's "civic leadership" ranking measures hospitals' investment in community health; the difference in compensation between executives and workers without advanced degrees; and how well patients reflect the demographics of the surrounding community. In Chicago, the top and bottom spots belong to St. Bernard Hospital and Northwestern Memorial Hospital, respectively. Another thing that differentiates the two institutions is the 30-year difference in life expectancy between Englewood, where St. Bernard is located, and Northwestern's Streeterville neighborhood.

Rounding out the top five locally are Norwegian American Hospital, St. Anthony, Roseland Community Hospital and Stroger Hospital, where Rivera ended up going for physical therapy.

Hospital finances generally reflect the socioeconomic status of their surrounding communities. Institutions in middle- and upper-income areas tend to get more commercially insured patients, while those in poorer areas treat more Medicaid beneficiaries and patients without insurance. Government-funded Medicaid, which covers lower-income people, reimburses hospitals at lower rates than private insurers. According to the latest state data, nearly three-quarters of patients at St. Bernard are on Medicaid or uninsured, compared with less than 10 percent at Amita Health St. Joseph Hospital in Lakeview, which Lown ranks No. 24 out of 25 Chicago hospitals.




"As a business person, it makes perfect sense to go where the revenue opportunity is," says Lown President Dr. Vikas Saini. "If you say, go where the rich people are or go where the white people are, it doesn't sound so good."

Hospitals are required by law to treat patients who need emergency care, regardless of insurance status or ability to pay. But hospital segregation persists outside the emergency room.

Sources point to different versions of so-called patient dumping, when hospitals transfer patients to another facility—or simply turn them away—based on their insurance or lack thereof.

According to a study published last year in JAMA Internal Medicine, adult patients with common pulmonary conditions who were uninsured or on Medicaid were more likely than privately insured patients to be transferred or discharged from emergency departments at hospitals that had the capabilities to provide the follow-up care those patients needed.

MATCHING

Experts say hospital systems generally try to match patients with services that meet their insurance status and financial situation, often directing the uninsured to public institutions, such as county-run hospitals and government-funded clinics. Cook County Health's two public hospitals, Stroger and Provident, provided more than half of all free care for low-income patients—about $348 million worth—in the county in 2018, according to the latest state data.

"The idea is, why saddle someone with a huge bill when it could be paid for through another avenue?" says Dr. Robert Bitterman, an attorney and former emergency physician. "Does this sometimes get taken to extremes and does it hurt people's access to care? Yeah, that happens. But, by and large, it's not a bad thing to try to align someone's care with the resources they can afford—provided you can get reasonable care through those avenues."

St. Bernard Hospital

St. Bernard Hospital in Chicago's Englewood neighborhood.

In addition to Northwestern and St. Joseph, the lowest-scoring Chicago hospitals ranked by civic leadership are Advocate Illinois Masonic Medical Center, Swedish Hospital and the University of Chicago Medical Center.

Swedish, which was acquired by NorthShore University HealthSystem this year, is the only safety net of the bunch. The Lincoln Square hospital "serves one of the most diverse communities in the country and our patients reflect that diversity," Swedish says in a statement, noting that its staff members speak more than 40 languages.

Advocate Illinois Masonic and UChicago Medicine say the ranking doesn't accurately reflect their commitments to equity, pointing to programs that aim to improve the health of their patients. But both organizations acknowledge there's still work to be done.

Northwestern says it "works closely with community partners to identify, develop and implement initiatives to improve equity, inclusion and community health."

Amita did not respond to a request for comment.

Meanwhile, Rush University Medical Center was the only Chicago hospital not included in the ranking. A Lown representative explains that hospitals with above a certain percentage of cancer, heart or orthopedic procedures were excluded so as not to skew clinical outcomes results.

Safety nets have "a strong incentive to try to keep their communities healthy and out of the hospital," Saini says. "They don't have a lot of resources, but still they'll do things like invest in food pantries or affordable housing. Many other hospitals that actually have the resources don't have the same incentives to do that. It's a problem of the system. It's not really any one hospital that's a hero or not."

Some industry observers, including the American Hospital Association, have criticized the Lown Institute ranking system for using only Medicare patient data and excluding some community benefit expenditures, such as professional training and losses incurred treating patients on government programs. But the institute says the direct benefit of such expenditures on community health has long been questioned by some health policy experts.

As for Rivera, he's getting physical therapy at Stroger several times a week to regain feeling in his leg. As frustrating as his health care journey has been since getting hit by a stray bullet during the unrest that unfolded following George Floyd's killing, Rivera says he's grateful for community groups like Enlace Chicago and Cook County Health that have helped him get the care he needed.

"There needs to be something done to make (health care) more affordable," Rivera says through an interpreter. "People should have access to it. It doesn't matter who you are. That's something we should strive for."



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