Boston. Racism. Image. Reality. Hospitals
Color line persists, in sickness as in health
The series was reported by Liz Kowalczyk, Todd Wallack, Nicole Dungca, Akilah Johnson, Andrew Ryan, Adrian Walker, and editor Patricia Wen. Today's story was written by Kowalczyk.
Patients fly in from all over the country to get care at Massachusetts General Hospital. Yet, most black Bostonians don’t travel the five to 10 miles from their neighborhoods to take advantage of the hospital’s immense medical resources. Just 11 percent of Bostonians admitted to the city’s largest hospital are black, far less than its peers.
The picture is similar at Dana-Farber Cancer Institute, one of the world’s top oncology centers. Nearly 2 in every 5 white Boston residents diagnosed with cancer are treated there, but, among black residents with the disease, it’s 1 in 5.
Across town, meanwhile, white residents of the South End are more likely than black residents to leave the neighborhood for inpatient care rather than go to nearby Boston Medical Center, once a public hospital. Blacks account for half of Boston patients at the former Boston City Hospital -- by far the most of any hospital in the city.
Though the issue gets scant attention in this center of world-class medicine, segregation patterns are deeply imbedded in Boston health care. Simply put: If you are black in Boston, you are less likely to get care at several of the city’s elite hospitals than if you are white.
The reasons are complex. More whites live near Mass. General. Certain lower-cost health insurance plans generally don’t pay for care at Harvard Medical School’s high-priced academic medical centers, including Dana-Farber and MGH. And some blacks are uncomfortable at mostly white institutions — or those institutions may not make them feel welcome — a divide compounded by a dearth of black physicians.
All of this creates likely disadvantages for blacks, who suffer far worse health overall than whites because of poverty and environmental reasons — a gap city planners recently said is persistent and growing. Some black leaders worry that blacks are handicapped because they don’t have, or don’t believe they have, the same array of health care choices.
“People in our own backyard should be able to utilize this resource,’’ said Dr. Christopher Lathan, one of the few black oncologists at Dana-Farber.
As part of its examination of whether Boston deserves its reputation as inhospitable to blacks, the Spotlight Team probed the forces driving segregation patterns in health care. The team obtained patient discharge and hospital employment data not generally available to the public, created databases, interviewed national researchers, and spoke to more than 50 black Bostonians about their health care experiences, and the conclusions were inescapable:
Despite a decade of intense and in some cases successful efforts by city leaders and high-ranking hospital officials to improve health care for minorities, certain patterns of segregation remain stubbornly entrenched, threatening to undermine the region’s mission of equitable care for everyone.
Massachusetts’ first-in-the-nation law mandating health insurance coverage, designed to increase equity in medical care, appears to have created greater — not less — hospital segregation, according to a scholarly paper published last year. The law increased the number of blacks with health insurance, and with that, potential access to a broader array of hospitals.
But they did not leave the institutions that have historically welcomed minorities, including Boston Medical Center. The concentration of minorities actually increased at these institutions, according to the paper.
“African-Americans in Boston are loyal to the old Boston City, because it was the hospital that served them when no one else would,’’ said Dr. Karen Lasser, who works at BMC and was the lead author.
Sometimes that loyalty is reinforced by experience. A young mother out for a walk with her toddler on a September afternoon said she was born at BMC and remained a faithful patient until she moved to Charlestown two years ago. Suffering from flu symptoms one night, she took the bus to the closest hospital: Mass. General.
There, the only other black person in the room was an inebriated man, said Monique, who did not want the Globe to print her last name. And she felt white staff treated the white patients more warmly than they did her. “I am out of my comfort zone,’’ she thought.
Officials at Mass. General, nationally known for its efforts to reduce disparities in health care, said in a written statement that hospital surveys show black and Hispanic patients feel they are treated the same as whites. Given the country’s history of discrimination, blacks may distrust the health care system and “even a seemingly small and subtle issue can be perceived as unfair and discriminatory,’’ according to the statement e-mailed by spokeswoman Peggy Slasman.
Indeed, stories of poor treatment while getting medical care are strikingly common among blacks. Eleven percent of black Bostonians reported being mistreated by health care professionals because of their race in the city’s health care survey in 2013, compared to 2.5 percent of white residents. Those numbers have barely budged over a decade.
Public health officials agree that one way to mediate this distrust is to hire more black physicians. But recruiting black medical professionals to the city has proved to be challenging, even at BMC, partly due to the city’s reputation rooted in events such as court-ordered busing in the 1970s.
“Those historic events that have occurred are still lingering in people’s minds,’’ said Dr. Thea James, a black doctor at BMC.
Deciding where to go
People tend to seek routine medical care close to home, so it’s not surprising that Mass. General, near the largely white and wealthy Beacon Hill neighborhood, has many white patients. It’s also a statewide referral center, with 70 percent of its patients coming from areas of Massachusetts outside Boston. And its health centers tend to be in or near Hispanic communities.
In the same way, it makes sense that Boston Medical Center, near large black populations in Roxbury and Dorchester, would treat many blacks.
But a Globe analysis of hospital discharges by where patients live shows that geography alone does not explain where they go. Even among residents of the neighborhoods that surround Mass. General — the Back Bay, Beacon Hill, Charlestown, East Boston, the North End, and the West End — whites were admitted to the hospital at twice the rate of blacks.
Or take the Fenway. More than one-third of patients in that neighborhood who were hospitalized over a five-year period went to nearby Brigham and Women’s Hospital or Beth Israel Deaconess Medical Center. But when they went to another hospital in the city, whites most often went to Mass. General, while blacks most often headed for Boston Medical Center.
Similar patterns can be seen with the two Boston hospitals owned by Steward Health Care: Blacks citywide tend to go to Carney Hospital in Dorchester, while whites are more likely to go to St. Elizabeth’s Medical Center, the company’s flagship teaching hospital in Brighton.
To uncover these neighborhood patterns, the Globe analyzed hospital discharge data by Boston ZIP code, comparing each hospital’s share of white patients and black patients. The Globe obtained data for fiscal years 2011 through 2015 for nine Boston hospitals from the Center for Health Information and Analysis, a state agency responsible for collecting and analyzing Massachusetts health care data. One caveat: zip codes don’t match neighborhoods exactly.
When looked at citywide, the data show that black Bostonians are more than three times as likely to get care at Boston Medical Center and nearly twice as likely to go to Carney as whites. About 43 percent of Boston patients at Carney are black.
Boston Medical Center, the primary teaching hospital for Boston University School of Medicine, is considered a good hospital by most measures, but in Boston, because of the competition, it survives in the shadow of the Harvard institutions.
Mass. General, meanwhile, is the mirror image: Whites are four times as likely to be admitted than blacks, though the hospital points out that it treats a larger number of Hispanic patients than black patients. Hispanics make up 16 percent of its outpatient primary care visits, for example, many at its community health centers in Revere and Chelsea.
Massachusetts Eye and Ear, next door to Mass. General, also sees a lower percent of black patients from Boston — 16 percent in its outpatient clinics — than the city population overall, according to data provided by the hospital.
At Dana-Farber, which provides mostly outpatient care, the hospital provided internal analysis to the Globe that also showed disparities. Overall, 83 percent of its patients are white and just 5 percent black. About half Dana-Farber’s 59,900 patients last year came for second opinions, seeking a review of their doctor’s original treatment plan.
Where whites and blacks in Boston go when hospitalized, 2011-2015
Click on a hospital to see the number of discharges by race, which generally reflects the racial makeup of patients at the hospital. The lines show where patients are discharged. Thicker lines indicate more patients discharged to an area.
Source: US Census and Boston Globe analysis of data from the state Center for Health Information and Analysis. The citywide discharge and ZIP code data is for fiscal years 2011 to 2015. Overall data is for fiscal year 2015.
Boston is far from the only city facing racially segregated health care, and its patterns appear to be far from the worst. In fact, some of Boston’s Harvard-affiliated teaching hospitals — the Brigham, Beth Israel Deaconess, and Boston Children’s Hospital — don’t appear to show the same racial imbalance, perhaps because they’re near black neighborhoods. At least 30 percent of Boston patients at all three are black, a higher percentage than the city’s black population as a whole, according to state data.
And a national study two decades ago ranked Massachusetts overall as having the 17th most segregated hospitals in the country.
Dr. Steffie Woolhandler, a longtime Boston physician, said she spent most of her career “criticizing the Boston teaching hospitals because they had effectively gotten the affluent white patients into one system and the minority patients in another system.’’
This was especially troubling since those hospitals, including the elite Harvard institutions, are nonprofits that receive substantial tax breaks.
But when Woolhandler recently moved to New York City, she was shocked by “how much worse the situation was’’ in that city. It appeared that poor and minority patients were crowded into New York’s network of public hospitals, she said, while well-off whites took advantage of the many academic medical centers.
A study she conducted with colleagues found that, indeed, black patients in Boston have better access to academic medical centers than in New York — mainly because of Boston Medical Center. If not for BMC, the researchers found, Boston and New York offered similarly unbalanced access.
“What we’re seeing here has kind of played out nationwide,’’ said Jonathan Jackson, a black neuroscientist at Mass. General and director of community outreach and engagement for the Lazarex-MGH Cancer Care Equity Program.
The data, of course, do not explain why patients go where they do.
Lathan, one of eight black doctors out of 359 employed by Dana-Farber, spends two days a month working at Whittier Street Health Center in Roxbury as part of the hospital’s outreach to underserved neighborhoods. There, he has learned a lot about why more black patients don’t seek out care at major cancer centers such as Mass. General and Dana-Farber.
The health care system’s labyrinth of rules and unyielding bureaucracy create high bars for even the most sophisticated and well-educated patients. The challenge of seeking care at Mass. General or Dana-Farber can seem overwhelming.
What should Boston hospitals do to be more welcoming and diverse?
Read the discussionDepending on insurance, you may be able to call these hospitals and make an appointment, or you may need a referral from a primary care doctor. And if your doctor works at a community health center with a close relationship with Boston Medical Center, you will likely be sent there.
For many blacks, there is “a perception of a hurdle,’’ Lathan said. ‘“I don’t think I can go there. Am I going to be allowed to go there?’ When patients get a diagnosis of cancer and they are in the western suburbs, they say, ‘You know what I am going to do? I am going to go into town and get a second opinion.’
“It’s a very Balkanized city,’’ he said.
Old turf lines endure
Some of today’s segregation patterns reflect the invisible hand of a referral system that dates back five decades.
In the late 1960s, Boston became one of the first cities to develop a network of community health centers to treat poor and working-class residents — a largely successful and enduring initiative that also contributed to the separation of health care in the city.
More than half of the city’s 22 health centers today are racially imbalanced — in part because Boston’s neighborhoods remain somewhat racially segregated.
Fifty years ago, the administration of Mayor Kevin White pushed the city’s well-off teaching hospitals to divide up the city and financially support health centers in their districts.
Boston City Hospital took many minority neighborhoods, while Mass. General got nearby and largely white Charlestown and the North End.
“When I talk to health center directors, many of whom are people of color, and their boards, they all say the same thing. They pride themselves on reflecting the needs of the population,’’ said James Hunt, president of the Massachusetts League of Community Health Centers. “Which is different than saying you are a certain race, you go to this health center. It’s not that way at all.’’
These divisions reverberate in other ways, too, as health center doctors are more likely to refer to the hospitals with which they have relationships. Dana-Farber treats 44 percent of Hispanic Bostonians with cancer, for example, which likely speaks to the power of its connections to community health centers in Jamaica Plain.
The long-ago divisions also created turf lines that may hinder some hospitals’ ability to attract minority patients. Mass. General leaders seem reluctant to step on toes by moving into neighborhoods dominated by BMC. In a written statement, Mass. General said such a strategy would be “destabilizing and disruptive to existing patient-provider relationships’’ and “quite disrespectful.’’
The hospital has provided $1.4 million in grant money to the Mattapan Community Health Center over the past 15 years for breast cancer care for black women.
Mass. General leaders said the goal is to reduce the mortality rate by identifying women with cancer earlier and making sure they get appropriate care, which the program has done. But because Mattapan is not an MGH health center, “it was difficult to make more significant inroads there,’’ in terms of programs, according to Dr. Joseph Betancourt, director of the Mass. General Disparities Solutions Center.
But the forces driving racial segregation patterns in health care go beyond old turf lines, who lives where, and patient preferences. There’s also another significant factor at play: money.
Blacks are disproportionately likely to be on Medicaid, called MassHealth, which pays hospitals at a lower rate than private insurers. In a startling sign of income inequality in Massachusetts, 40 percent of non-elderly blacks are on Medicaid — more than twice the rate for whites.
The Harvard teaching hospitals treat a large number of MassHealth patients, given their size, but poor patients account for a much higher percent of patients at Carney and BMC — a hospital that actually seeks out this group.
And MassHealth insurance plans increasingly say they cannot afford to pay for care at Mass. General, the Brigham, and Dana-Farber. Of six Medicaid managed care plans, serving about 800,000 residents, only one — Neighborhood Health Plan — typically pays for care at Mass. General and the Brigham. All are owned by the same company, Partners HealthCare. Only two plans routinely pay for care at Dana-Farber.
This means, for example, that in the middle-class North End, where there are few black residents and most patients have private insurance, the community health center sends people to Mass. General. But at the health center’s satellite in a Charlestown low-income housing development, which has a sizeable Medicaid population, many patients are sent across town to BMC.
The differences among hospitals
In reality, the impact on patients of segregation in the Boston health care system is unknown.
In part, that’s because BMC is a good hospital, good enough that James Luisi, chief executive of the North End Waterfront Health, said he is fine with sending his patients there instead of Mass. General.
Azzie Young, who heads the health center in Mattapan, said that equity is because “we don’t have the kind of disparities we have in the schools. The quality is good wherever you go.’’
And so many factors — rundown housing, exposure to environmental toxins, and poverty — contribute to high rates of disease and death for the city’s blacks that it’s hard to tease out any harm from access to different health care.
However, it would be a mistake to say there’s no difference among hospitals. Consider: U.S. News & World Report ranks Mass. General as the number four hospital in the nation, and Dana-Farber/Brigham and Women’s Cancer Center and Mass. Eye and Ear as the fourth best hospitals in cancer and ophthalmology, respectively.
Medicare, the federal health insurance program for the elderly, gives Mass. General four out of five stars overall, compared to three stars for BMC and Carney, the same score as the Brigham and Beth Israel Deaconess. For mortality and complications, MGH is better than the national rate on five measures, BMC on two, and Carney on none. But in areas of patient satisfaction, such as getting help as soon as they wanted, BMC lags. This may speak to tighter resources at a hospital where doctors say there are also long waits to see dermatologists and other specialists. Carney scored worse than both on overall patient satisfaction.
Another difference is in cancer treatments.
When it comes to innovative care, Dana-Farber and the other Harvard teaching hospitals offer more options to patients.
Clinical trials test standard therapy against promising, yet unproven, therapy. Along with access to potential cutting-edge drugs, patients who enroll in trials generally get closer management and more testing, all highly sought-after benefits that many cancer patients want to exhaust before yielding to a terminal prognosis.
BMC lists seven clinical trials for breast cancer and six for lung cancer on its website, compared to 63 for breast cancer and 45 for lung cancer listed at Dana-Farber across town.
Dr. Ravin Davidoff, senior vice president of medical affairs at Boston Medical Center, said he would welcome Mass. General, the Brigham, and Dana-Farber in the hospital’s Medicaid insurance network, but they are too expensive. “It’s not realistic for us to pay the prices that are asked at those hospitals,’’ he said.
Mass. General and the Brigham, for example, charge 59 percent more than BMC for the same services, according to the state Health Policy Commission.
“Does it perpetuate the disparities?” asked Davidoff. “It probably does.’’
Still, he said, BMC is highly experienced at caring for diabetes, high blood pressure, obesity, and other medical conditions more commonly faced by lower-income people, and it has put in place support services, such as a food pantry, that other institutions lack. And, he said, patients at Boston Medical Center get excellent care for common cancers — and are sent to outside specialists for rare or complicated diagnoses.
“For all the high volume cancers, we have incredible expertise and can compete with anybody,’’ Davidoff said.
But differences in where blacks and whites get medical care in Boston have rarely been part of the health care debate — and researchers say it should be. It hasn’t been anywhere else, really, according to Dr. Ashish Jha, a health policy professor at the Harvard School of Public Health, who has found that nationally about 5 percent of hospitals care for about 50 percent of blacks.
“Segregated schools and communities get a lot of attention and segregated health care does not,’’ he said. “Part of it is the belief that we can improve these minority-serving institutions so they can provide comparable quality. We don’t make the same argument in education.’’
Tough place for black doctors
When then-Mayor Thomas Menino convened Boston’s leaders and residents in 2004 to develop a plan to address racial disparities in health care, the group heard repeated complaints from minorities about insensitive racial comments from providers and an unwillingness to communicate important medical information. That insensitivity was in part due to a dearth of minority providers, the group concluded.
More than a decade later, a Globe survey of 12 Boston hospitals found that only BMC and Carney match or exceed the national average; 4 percent of doctors are black.
The Globe asked the hospitals to voluntarily report the racial breakdown of their employees. All agreed.
Mass. General and Dana-Farber reported between 2 and 3 percent black physicians, while Mass. Eye and Ear and New England Baptist Hospital each employ one black doctor out of 192 and 34 physicians, respectively. Dana-Farber, Mass. Eye and Ear, Mass. General, Children’s, and Tufts have the lowest percent of black employees overall and the lowest percent of black managers.
Executives at three hospitals — BMC, Carney, and Mass. General — said recruiting efforts have been hurt by Boston’s reputation as unwelcoming to blacks. “It’s hard for us to refute what people feel around them,’’ said Davidoff of BMC. “It’s a tough place for black physicians to find colleagues.’’
The Globe interviewed 50 black Bostonians about where they get their medical care. They said they sought treatment in hospitals across the city for a host of reasons: location, referrals, expertise — and comfort. Time and again, those interviewed said they also found solace when they received care by people who looked like them.
Percent of black doctors at Boston hospitals
* Children's data includes only doctors employed directly by the hospital, which is 8 percent of its physicians.
** The Brigham and Faulkner share physicians.
Source: The hospitals
No matter where they go for medical care, many black residents seem deeply distrustful of medicine generally and often mention the country’s ugly history of medical experimentation on blacks without their knowledge. And many said they had experienced discriminatory comments or bias.
Shirley Coffey, 78, grew up in the Albany Street housing development, a quick walk to what was then Boston City Hospital. Her childhood did not include visits to a Harvard teaching hospital. “You had to have money to go to the other places, and we didn’t have money,’’ she said.
Years ago, her late husband talked her into going to the Brigham. He heard it was newer, cleaner, less crowded. But as she waited in the emergency room, she perceived unfair treatment. White patients who arrived after her got called back to see a doctor sooner, she said. She cooled her heels while the minutes ticked by. Eventually she got up and left.
“I didn’t feel comfortable there,’’ Coffey said.
The Brigham said it’s confident patients today are treated equally. But decades later, that memory sticks in Coffey’s mind.
“There are generations of people who felt powerless to say, ‘No, you will not treat me like that,’’’ said her son Michael Kincade, whose own longtime doctor is at the Brigham and Women’s Faulkner Hospital in Jamaica Plain. “Their decisions were based on where they were going to be treated most humanely.’’
Mass. General president Dr. Peter Slavin spoke to colleagues in Baltimore two years ago, shortly after Freddie Gray suffered fatal spinal injuries in a police van, his pleas for medical attention ignored, sparking protests over police brutality. “The mistrust that people may have for police mirrors the mistrust they feel for the health care system,’’ Slavin told his audience of doctors.
Mass. General was one of the first hospitals to conduct its own internal surveys and analyze quality of care by race, reports it publishes online in part to build trust in minority communities. Those suggest that blacks who do get care at the hospital rate it highly -- though just five percent of MGH’s patients overall are black.
In 2004, 21 percent of black patients felt as though the white patient next to them was receiving better care. But when the hospital examined waiting times, for example, it found that they were all the same, Slavin said in his speech.
“When we dug deeper, it turned out that a big part of our patients’ experiences were shaped by how they were greeted and engaged by our frontline staff when they first walked into the hospital or an outpatient practice,’’ Slavin told his Baltimore audience, adding that staff training has closed the satisfaction gap.
But some black leaders say Mass. General and the city’s other elite hospitals don’t do enough to truly make minorities feel welcome.
Jackson, the Mass. General neuroscientist, said doctors often talk to blacks about their medical problems in what patients feel is an accusatory manner: “You are at risk for heart attack or stroke because of the choices you’ve made, the food you eat, the stress you have.” Patients, he said, end up feeling like they “are being made very small.”
Sometimes it goes beyond perception.
At the Twelfth Baptist Church in Roxbury this fall, a group of veterans described hearing racially charged comments at a range of medical facilities in recent years, from being referred to as “a big black lady’’ who could handle extra anesthesia during a dental procedure, to being told “you people eat of lot of fried food, don’t you?’’ when treated for a grease burn.
David Purvis, 64, a master’s-level therapist who counsels veterans, saw a doctor at a Veterans Affairs hospital in Jamaica Plain for a checkup this summer and complained of heart palpitations.
“One of his first questions was, ‘Are you using cocaine?’ ” Purvis recalled. “I laughed. I told him I didn’t, but he ordered a urine test anyway.’’
To contact the Spotlight Team working on this project, write to [email protected] or contact the writer of this story at [email protected].
What should Boston hospitals do to be more welcoming and diverse?