Disparities in Cardiac Care:
A Preview from 10 Communities
Marsha Regenstein, PhD, Holly Mead, PhD,
Anthony Lara, MHSA
Academy Health Annual Research Meeting
June 25, 2006
Expecting Success: Excellence in Cardiac Care
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National program of RWJF that combines quality improvement
work with strategies to reduce disparities associated with the
delivery of heart care in U.S. hospitals.
10-hospital learning collaborative over 29 months
Cardiovascular market assessments support work of ES:
 Multiple market factors contribute to minority/ethnic patterns in
care that may result in suboptimal care
 Ultimately, provision of care segmented based on patients’ ability
to pay
 Racial/ethnic disparities result as an outcome of market
segmentation
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Series of products: confidential bulletins for grantees and public
reports
Expecting Success Sites
Mount Sinai Hospital
Chicago, IL
Montefiore Medical Center
New York, NY
Sinai-Grace Hospital
Detroit, MI
Washington
Hospital Center
Washington, DC
Duke University
Hospital
Durham, NC
Del Sol Medical Center
El Paso, TX
University Health System
San Antonio, TX
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Memorial Regional
Hospital
Hollywood, FL
University of Mississippi
Medical Center
Jackson, MS
Delta Regional Medical Center
Greenville, MS
CV Bulletins 1: Methodology
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Two-day site visits to grantee hospitals and other
key providers of cardiac care in each community.
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Interviews with approximately 300 contacts: hospital
and health center leaders, cardiologists, primary
care physicians, advocates, health department
officials, others.
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Information from U.S. Census Bureau, the Centers
for Disease Control and Prevention, local health
departments, peer-reviewed literature, local reports.
Factor 1: Health Care Financing
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Business and financial considerations lead to segmented
care by insurance coverage and ability to pay.
 Hospitals, physicians must maintain financial viability in
order to fulfill responsibilities
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Often results in “skimming” phenomenon
 Well insured patients attracted to facilities that market to
this patient population
 Uninsured, Medicaid populations cluster at facilities known
to treat this poorer patient population
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Minorities affected by skimming due to high proportions
of uninsured and Medicaid
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Factor 2. Market Segmentation
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Objective – to grow market share by
 Providing high-end medical care and other amenities
 Attracting privately insured, Medicare patients who can pay for
specialized care
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May result in racial and ethnic disparities
 Minorities disproportionately represented among the uninsured
and publicly insured
 Effectively shuts them out of this care
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Manifested at both the market and hospital level
 Development of high-end specialty cardiac hospitals
 Development of floors, suites or other non-clinical amenities
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Factor 3. Availability of Resources
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Few hospitals, physicians have sufficient resources
to offset the costs of care for the uninsured.
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Federal, state and local resources to support care
for the uninsured include:
 Federally qualified community health centers (FQHCs)
 Public hospitals with safety net mandate
 State or local indigent care programs
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Without dedicated resources health care providers
struggle to meet the cardiac care need of residents
Factor 4. Referral Patters
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Income, insurance status drive the referral process
 Low-income, uninsured or underinsured patients are referred to
the lower tiers of the health care system
 Privately insured patients are directed to the top tier of the health
care system
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Key referral pathways in heart care
 Provider to provider referral practices
 Referral pathways into the Hospital “Front Door”
 Referral pathway into the Hospital Emergency Department
Provider to Provider Referral Relationships
By Insurance Coverage
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Provider to Hospital Referral Pathways By Insurance
Coverage: “Front Door” vs. Emergency Department
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5. Coordination of Cardiac Care Across Multiple
Sites and Providers
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Coordinated cardiac care consists of
 communication and coordination among primary, specialty,
inpatient providers
 monitoring of patient adherence to treatments
 tracking referrals
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Lack of coordinated care can lead to poorer health outcomes
 Attention to only episodic care
 Duplication of services
 Frustration among patients
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Coordinated cardiac services a challenge for racial and ethnic
minorities
 More likely to lack medical home who can manage disease
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What Can Hospitals Do to Improve Care for
Minority Patients with Heart Disease?
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Data is power: collect and analyze utilization patterns
and outcomes for all patients by race, ethnicity and
language
Form collaboratives with other community resources
(CBOs, hospitals, CHCs, etc)
Develop strategies to address challenges facing many
minority patients (e.g., access to pharmaceuticals,
specialists, care management)
Bring health care closer to the community: education,
outreach, networks/contacts.
Improve coordination of services and shared information
across points of care.