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Racial and Social Justice in Health

Paper Session

Sunday, Jan. 9, 2022 10:00 AM - 12:00 PM (EST)

Hosted By: Health Economics Research Organization
  • Chair: Amitabh Chandra, Harvard University

COVID-19 -Hospitalizations, Mortality, and Racial/Ethnic Disparities in the COVID-19 Pandemic

Zirui Song
,
Harvard University
Lindsey Patterson
,
Harvard University
Luka Zhang
,
Avantgardehealth
C. Lowry Barnes
,
University of Arkansas
Derek Haas
,
Avantgardehealth

Abstract

Importance: The COVID-19 pandemic has disproportionately affected racial/ethnic minority populations. However, racial/ethnic disparities in hospitalizations and hospital outcomes during the COVID-19 pandemic remain poorly understood, especially among older populations.

Objective: To assess racial/ethnic differences in hospitalizations and in-hospital mortality during the COVID-19 pandemic in the Medicare population.

Design, Setting, and Participants: Using 100% Medicare hospital inpatient data from January 2019 through December 2020, we examined changes in COVID-19 and non-COVID-19 hospitalizations and outcomes, focusing on in-hospital mortality, relative to the pre-pandemic baseline. Using a difference-in-differences model adjusted for age, sex, risk score, and month and hospital fixed effects, we measured differential changes in outcomes between racial/ethnic minority patients collectively and White patients attributable to the pandemic. We separately compared Black vs. White patients and Hispanic vs. White patients in subgroup analyses. Sensitivity analyses and falsification analyses tested the robustness of our results.

Exposures: Race/ethnicity of the patient as reported in Medicare claims from the Social Security Administration.

Main Outcomes and Measures: The main outcomes included hospitalizations and in-hospital mortality. Secondary outcomes included discharges to hospice and discharges to post-acute care.

What Does Accreditation Do? A Randomized Trial of Health Care Accreditation across US Jails

Marcella Alsan
,
Harvard University
Crystal S. Yang
,
Harvard University

Abstract

Jails admit nearly 11 million individuals each year (Subramanian et al. 2015, Zeng and Minton 2021), including a high number of inmates with mental illness, substance abuse disorder, infectious diseases, and other serious illnesses. Since the Supreme Court’s landmark decision in Estelle v. Gamble (1976), federal and state correctional systems (including prisons, jails, and juvenile detention facilities) have been constitutionally mandated to provide “reasonably adequate” health care to the incarcerated population. In addition, the Supreme Court held that “deliberate indifference to serious medical needs of prisoners” constitutes an Eighth Amendment violation. Yet, unlike health care systems that provide services to the non-incarcerated population, there is no “deemed status” (a convention provided by agencies such as the Joint Commission that guarantees the health care provider is eligible for reimbursement from Medicare and Medicaid services) to incentivize accreditation (Joint Commission 2018). As a result, many facilities are not guided by a specific set of standards to inform their delivery of health care services, resulting in increased variability in preventable morbidity/mortality for both inmates and staff.

In this study, we randomize the offer of fully subsidized health care accreditation via the National Commission on Correctional Health Care (NCCHC) to medium-sized jails. NCCHC, the organization that pioneered standards for jail health care services, operates a voluntary accreditation program based on a set of consensus-driven standards that provide a framework for the care inmates receive. While nearly half a million inmates are served in NCCHC-accredited facilities every day and adoption of NCCHC accreditation has rapidly grown, its impact has not been rigorously evaluated. We hypothesize that the process of preparation, verification, and maintenance of accreditation will improve inmate healthcare access, delivery, and outcomes; increase satisfaction and retention among correctional staff; promote cultures of safety in jails; and reduce recidivism, litigation, and health care costs for jails.

Capacity Strain in Hospitals and Racial Disparities in Mortality

Manasvini Singh
,
University of Massachusetts
Atheendar Venkataramani
,
University of Pennsylvania

Abstract

A growing literature has documented racial disparities in health outcomes. We argue that racial disparities may be magnified when hospitals operate at capacity, when behavioral and structural con- ditions associated with poor patient outcomes (e.g., limited provider cognitive bandwidth or reliance on ex ante biased care algorithms) are aggravated. Using detailed, time-stamped electronic health record data from two major hospitals, we document a 20% relative increase in mortality for Black compared to White patients as hospitals approach capacity, driven entirely by patients with more medical comorbidities. Put differently, 8.5% of Black patient deaths in our sample could have been avoided if Black patients had experienced the same mortality-capacity relationship as White patients. In terms of potential mechanisms, Black patients experienced longer wait times, lower likelihoods of ICU admissions, and had shorter lengths of stay and charges, though this was true at all levels of capacity strain. Decomposition analyses suggest that these findings were most likely driven by additional biases in provider behavior, hospital processes, and/or allocation of care resources that emerge or worsen as strain increases, and interact with already lower intensities of care to produce differential mortality risks.

Discussant(s)
Joseph Benitez
,
University of Kentucky
Alberto Ortega
,
Indiana University
Noah Hammarlund
,
University of Washington
JEL Classifications
  • I1 - Health
  • I1 - Health