BY JAY HANCOCK
KAISER HEALTH NEWS
TRIBUNE NEWS SERVICE
BALTIMORE — The Baltimore health system put Robert Peace back together after a car crash shattered his pelvis. Then it nearly killed him, he says.
A painful bone infection that developed after surgery and a lack of follow-up care landed him in the operating room five more times, kept him homebound for a year and left him with joint damage and a severe limp.
“It’s really hard for me to trust what doctors say,” Peace said, adding that there was little after-hospital care to try to control the infection. “They didn’t do what they were supposed to do.”
Pushed by once-unthinkable shifts in how they are reimbursed, Baltimore’s famous medical institutions say they are trying harder than ever to improve the health of their lower-income neighbors in West Baltimore.
But dozens of interviews with patients, doctors and local leaders show multiple barriers between the community and the glassy hospital towers a few blocks away.
Suspicious of system
Reporters from Kaiser Health News and the University of Maryland’s Philip Merrill College of Journalism spent much of the fall in and around Sandtown-Winchester, a Baltimore neighborhood where violence flared last year after Freddie Gray was fatally injured in police custody.
Residents say they have little more confidence in the medical system intended to heal them than in the criminal justice system intended to protect them.
Even though his accident happened in 2004, Peace says he cannot view doctors and hospitals with anything less than deep suspicion.
“They almost let me die,” he said.
Disparity in services
As with so much else, there are two Baltimores when it comes to health. One population is well off and gets the best results from elite institutions on the city’s west and east sides, the University of Maryland Medical Center and the Johns Hopkins Hospital.
The other is a poor minority that gets far less, even as it uses hospital services at higher-than-average rates. One indicator: The typical Sandtown resident lives a decade less than the average American.
“They come in with a great service, but they don’t have relationships with people in the community,” said Louis Wilson, senior pastor of New Song Community Church in Sandtown, a small wedge of about 5,000 households. “They want the people in the community to come in and respect them, but they don’t respect the people in the community. It does not work. It just doesn’t.”
The gap is more than the cultural distance between lower-income African-Americans and the wealthier practitioners, often of other ethnicities, who treat them, although that’s a part, Wilson said. It’s about insurance that is still unstable, confusing and perceived as expensive despite the health law’s recent expansion of Medicaid for low-income patients.
It’s about a system that still treats too many residents in the most expensive way possible — in crisis visits to the emergency room — rather than keeping people healthy in the community. It’s about having too few primary-care doctors addressing everyday needs to change that.
It’s about inadequate transportation to get to appointments and jail stays that cut patients off from family doctors. It’s about avoiding medical institutions often seen in the same light as the justice system that held Freddie Gray when he died: as biased, haughty and dangerous.
“When you walk into a hospital, it’s like walking into a courtroom,” said William Honablew Jr., who volunteers at LIGHT Health and Wellness, a nonprofit whose community services include helping those with HIV and other chronic illness navigate the system. “You know who’s in charge, and you know who’s not.”
Haunted by the past
Many in Sandtown have heard of Henrietta Lacks, an African-American woman whose tissue was used without permission by Johns Hopkins Hospital in the 1950s to establish a line of experimental cells.
For years, Baltimore Blacks associated Hopkins, on the city’s east side, with the “night doctors” of African-American folklore who supposedly kidnapped Black children for medical experiments, residents and community leaders say.
Bon Secours Baltimore Health System, Catholic, nonprofit and the nearest inpatient provider to Sandtown, has reduced potentially deadly, in-hospital hazards such as pneumonia and blood and urinary tract infections in recent years. Adjusted for illness severity, its death rates for Medicare patients with major conditions such as heart failure and stroke are little different from national scores.
But to the frustration of hospital officials who say they deserve better, Bon Secours is still known across West Baltimore as “Bon Se-Killer.”
“I lost two aunts in that hospital, an uncle and two cousins. Five people,” said Arnold Watts, 60, in a grim accounting matched, unprompted, by several other residents interviewed.
The average Sandtown resident lives to be 69.7 years old, according to the Baltimore City Health Department — the same as life expectancy in impoverished North Korea.
Detailed data from the Maryland agency that regulates hospital prices, seldom seen by the public, illustrate why.
Residents of the ZIP code including Sandtown accounted for the city’s second-highest per-capita rate of diabetes-related hospital cases in 2011, the second-highest rate of psychiatric cases, the sixth-highest rate of heart and circulatory cases and the second-highest rate of injury and poisoning cases. Asthma, HIV infection and drug use are common.
Two out of 10 babies born in Sandtown in 2013 were underweight — the highest percentage in any of Baltimore’s 55 neighborhoods. The share of Sandtown mothers getting early prenatal care fell by 25 percentage points in 2013 from the year before.
Dr. Jay Perman is a pediatric gastroenterologist who is president of the University of Maryland, Baltimore, which shares its downtown campus with the University of Maryland Medical Center.
Perman, who says the school has a critical role to play in fighting poverty, looks out of his 14-floor paneled office across a boulevard that marks the beginning of Baltimore’s poor west side.
“Why,” he asks, “in the midst of this extraordinary health care enterprise that is present in Baltimore, with all this expertise, are we sitting here on this side of Martin Luther King (Blvd.) and on the west side of Martin Luther King (Blvd.) you have some of the most disappointing life expectancies that one could imagine?”
Two miles away, residents such as David Johnson start to provide an answer. Johnson, 52, sits in the nave of First Mount Calvary Baptist Church, waiting for food bank vegetables and talking about being newly out of jail, lacking identification and trying to qualify for Medicaid.
Police arrested Freddie Gray, 25, five blocks from the church last April, allegedly for carrying an illegal switchblade. He died of spinal injuries that prosecutors filing manslaughter charges blamed on police.
Western District police station, where officers removed Gray’s unconscious body from a prisoner van and protesters surged a week later, is a block south.
“I think I have diabetes,” said Johnson. “I know I have high blood pressure. I know that. I get dizzy a lot, especially when I wake up in the morning. I need to see a doctor.”
But he can’t. Baltimore jail authorities lost his identification cards, he said, before releasing him in October from an 11-month stay related to a drug arrest. He spent weeks reapplying for a Motor Vehicle Administration identification card, which social workers said he needed to qualify for Medicaid.
“You need ID to get ID, you know?” he joked. Nobody told him he could use incarceration credentials to qualify.
Medicaid’s expansion to include low-income adults was seen as an unprecedented opportunity to cover former inmates such as Johnson as they rejoin the community. (Inmates are not usually eligible while incarcerated.)
But limited administrative resources for release planning means sign-ups are often limited to the most severely ill, said Lena Hershkovitz, a vice president with HealthCare Access Maryland, a nonprofit working to increase enrollment.
“I know for a fact that he’s not unusual,” she said of Johnson. “I would say the majority of people leaving the prison or detention system are leaving without Medicaid.”
Even when patients get access, care is disrupted by physician turnover, poor follow-up or insurance companies’ changing medical networks.
“The system is fragmented,” said Debbie Rock, who has run LIGHT Health and Wellness, on Sandtown’s western edge, since the 1990s. “I think that people need to go back and talk to each other. I think the doctors and the health insurance companies need to sit down and listen to each other.”
One homeless West Baltimore patient left an oral surgeon’s office with a wired jaw and no way to pay for the liquid nutrition he needed to feed himself, said Carol Marsiglia, senior vice president at the Coordinating Center, a nonprofit consulting organization that is working to reduce readmissions and emergency visits in the neighborhood.
A home oxygen company wouldn’t serve a discharged lung patient because he had a $27 balance, she said. A hospital directed two home health companies to teach a patient how to deal with a new colostomy bag; neither showed up. The Coordinating Center fixed the breakdowns.
Poverty makes Sandtown’s health worse. Many say poverty causes Sandtown’s poor health.
Many residents hold jobs in government or manufacturing, run churches or collect pensions from the military or Social Security. Even so, the median Sandtown household income in 2011 was $22,000.
Roofs leak. Mold and mildew grow. Baltimore Gas and Electric cuts off energy to Sandtown households for nonpayment at twice the rate it does in the rest of the city. Lead paint violations like the kind that allegedly poisoned Freddie Gray are nearly four times higher in Sandtown than in Baltimore as a whole.
Drug and alcohol use are common. Diets are often poor. Many lack cars and the nearest supermarket is more than a mile away from the church.
“If we walk around this block, we’ll pass four liquor stores and three sub shops,” said Derrick DeWitt, pastor of First Mount Calvary, on Fulton Avenue.
Even small copayments required by many health plans dissuade low-income West Baltimore residents from seeking care, the John Snow report found. Some constantly switch doctors to find the lowest price, leading to “disjointed services” and potential harm if information falls in the cracks, it found.
“I change doctors like I change underwear,” said Eddie Reaves, 64, who tries to find practices that won’t charge him copays as little as $12 or $15. His income is $1,170 a month, he said. In 2014, he added, “I must have seen a good total of about 10 doctors.”
Reaves has diabetes and high-blood pressure. He’s on Medicare because of a disability. He has applied twice to Medicaid since the health law expanded coverage two years ago. That would improve his benefits. But he never received the paperwork, he said.
The best care he ever received, Reaves said, was when he didn’t need any insurance card — when he was homeless.
Health Care for the Homeless, a nonprofit a couple miles east of Sandtown, delivers comprehensive services to the homeless without regard for ability to pay.
By many accounts, hospitals, doctors, health plans and governments in Annapolis, Maryland’s capital, and Washington are making unprecedented efforts to bridge the medical divide with Sandtown and the rest of low-income Baltimore.
The grand idea is to save money and simultaneously improve lives by keeping people healthier in the community instead of letting them become ill enough to land in the hospital.
In October Bon Secours bought a nearby church that it intends to turn into a primary care and wellness center. UMMC and Bon Secours are working with “transition coaches” from the Coordinating Center to make sure people leaving the hospitals take medicine and schedule follow-up appointments. UMMC’s transition clinic serves hundreds of recently discharged patients.
‘Health enterprise zones’
Maryland is developing one of the most advanced electronic networks for letting medical providers collaborate by sharing patient records. Health Care for the Homeless has opened a clinic in Bon Secours.
Dr. Samuel Ross, Bon Secours’ CEO, talks about working more closely with the churches and continuing to improve the hospital’s outcomes and reputation.
“No, it’s not solved,” he said. “We need to keep doing what we’re doing, and understand that some of this is a person at a time. There is no wholesale campaign or branding message that’s going to cause people to say, ‘You’re wonderful.’”
In 2012 Maryland’s legislature created “health enterprise zones” to increase the supply of primary caregivers in West Baltimore and other underserved areas. UMMC puts emergency room patients in touch with a primary care doctor if they don’t have one.
In September hospitals proposed taxing insurance companies, employers and other payers so they could hire up to 1,000 caregivers directly from West Baltimore and other low-income communities with poor health results.
The Baltimore health department is pressing hospitals to collaborate on high-risk patients and is building ties with lower-income neighborhoods by hiring residents, said Dr. Leana Wen, the city’s health commissioner.
Baltimore’s B’more for Healthy Babies program has reduced the city’s African-American infant mortality rate by nearly a third since 2009, to 12.8 per thousand births. But that’s still a fifth higher than the African-American rate for all of Maryland.
University of Maryland Medical Center has workshops and internships for high schoolers interested in health careers. The University of Maryland, Baltimore, got a federal grant to mentor and train West Baltimore middle schoolers to increase the number of African-Americans in health care jobs.