Payment sources and patient racial mix at academic medical centers

Hospital Payer and Racial/Ethnic Mix at Private Academic Medical Centers in Boston and New York City

By Roosa Sofia Tikkanen, Steffie Woolhandler, David U. Himmelstein, Nancy R. Kressin, Amresh Hanchate, Meng-Yun Lin, Danny McCormick, Karen E. Lasser
International Journal of Health Services, February 2, 2017


Academic medical centers (AMCs) are widely perceived as providing the highest-quality medical care. To investigate disparities in access to such care, we studied the racial/ethnic and payer mixes at private AMCs of New York City (NYC) and Boston, two cities where these prestigious institutions play a dominant role in the health care system. We used individual-level inpatient discharge data for acute care hospitals to examine the degree of hospital racial/ethnic and insurance segregation in both cities using the Index of Dissimilarity, together with recent changes in patterns of care in NYC. In multivariable logistic regression analyses, black patients in NYC were two to three times less likely than whites, and uninsured patients approximately five times less likely than privately insured patients, to be discharged from AMCs. In Boston, minorities were overrepresented at AMCs relative to other hospitals. NYC hospitals were more segregated overall according to race/ethnicity and insurance than Boston hospitals, and insurance segregation became more pronounced in NYC after the Affordable Care Act. Although health reform improved access to insurance, access to AMCs remains limited for disadvantaged populations, which may undermine the quality of care available to these groups.

From the Introduction

Academic medical centers (AMCs) play a unique role in the U.S. health care system. These institutions, which typically comprise a medical school and a closely affiliated teaching hospital, train health professionals, conduct research, and provide patient care. AMCs are often among the largest hospitals in their service areas: despite representing only 5% of the nation’s hospitals, combined, they account for one-fifth of the total hospital volume in the United States. AMCs typically serve a medically complex patient population and provide specialized expertise across a range of clinical areas. Many AMCs are ranked among the top hospitals in the country, and patients treated at AMCs are more likely than other patients to receive treatments using the latest technologies and care adhering to current clinical guidelines.

For these reasons, AMCs are often recognizable brands and attract referrals from nearby counties, states, and, increasingly, from other countries as well. At the same time, many AMCs are key safety-net providers in their communities and have historically provided approximately one-third of all charity care and one-quarter of all Medicaid hospitalizations. Yet, recent reports raise concern that uninsured and Medicaid patients face barriers to obtaining care at AMCs.

Racial and ethnic minorities, who are more frequently uninsured or covered by Medicaid than other Americans, often encounter access barriers. Unequal access to high-quality health facilities, including AMCs, is recognized as a contributor to racial and ethnic health disparities.

From the Discussion

Our analyses of adult hospital discharges indicate that minority, uninsured, and Medicaid patients are strikingly underrepresented at NYC’s private AMCs. This pattern has not improved and - regarding insurance status — became even more pronounced after the passage of the ACA. In contrast, care was less segregated according to both race/ethnicity and insurance in Boston. Indeed, minorities were slightly overrepresented, although Medicaid and uninsured patients were underrepresented, at Boston’s AMCs.

What explains the greater racial/ethnic and payer segregation in NYC’s AMCs relatives to Boston’s? First, the extensive network of public hospitals in NYC relieves pressure on that city’s private AMCs to care for disadvantaged patients, allowing AMCs there to focus on serving as referral centers for privately insured patients living in predominantly white, suburban communities. In contrast, only one relatively small public hospital remains in the Boston area. Second, AMCs in Boston may be less resistant to integrating the comparatively small number of minority and uninsured patients in that city. Finally, Boston Medical Center, a private AMC that incorporates a previously public hospital, continues to serve many poor and black patients.

The case for desegregation is morally and medically compelling. Disparities in access to high-performing health facilities contribute to racial/ethnic disparities in both quality of care and health outcomes. Ensuring equal access to health facilities is a stated policy priority of both federal and NYC authorities.



By Don McCanne, M.D.

Academic medical centers (AMCs), with their great resources and advanced technologies, are ideal to provide specialized care for certain patients with complex medical needs. A high performance health care system should provide equitable access for those who would most benefit from the services offered by AMCs. This study indicates that race and insurance status may contribute to inequities and disparities in access to these facilities.

There are many contributing factors, some of which are discussed in the article. It is clear that one significant factor is the fragmentation in the financing of health care - both in funding of the health care delivery infrastructure and in the various forms of public and private insurance coverage or lack thereof.

Patients are treated differently based on whether they are uninsured, or if they are on Medicaid with its low reimbursement rates, or on the basis of the richness or sparseness of the benefits offered by their private plans, or on the makeup of the provider networks established by their insurers.

A single payer national health program, including separate allocation of resources for health care delivery infrastructure, would dramatically reduce the role of financing factors that result in these inequities.

Once we have an equitable financing system, other racial factors must still be addressed. As study co-author David Himmelstein states, “Stark racial segregation persists to this day in New York’s hospitals. Our most prestigious institutions find ways to avoid Black and poor patients. And they maintain separate and unequal clinic systems. Privately insured patients get business-class care; those with Medicaid are mostly treated by interns and residents in rundown facilities and face long waits for appointments; while the uninsured are usually turned away from the elite hospitals’ clinics altogether.”

Clearly, once we have an improved Medicare for all in place, our work is not done.