Hospitals and policymakers have said they want to prioritize health equity, and now they’re demanding the same from hospital rankings. How could this change hospital metrics?
US News gets challenged
Two hospital systems in Pennsylvania, Penn Medicine and St. Luke’s, recently announced they would no longer participating in the US News & World Report “best hospitals” ranking. Around the same time, the city attorney of San Francisco sent a letter to US News about issues with their ranking, indicating they may be launching an investigation.
What’s driving this opposition? The biggest issue is health equity. David Chiu, the city attorney of San Francisco, pointed out that the US News‘ ranking prioritizes certain services over others– such as specialty care over primary care– that gives hospitals incentives to cater to more privileged patients. Their method of risk adjustment also may penalize hospitals that care for the very sickest patients.
Even within specialties, patients of color are sidelined, Chiu noted. For example, children’s hospitals are awarded more points for treating cystic fibrosis than sickle cell disease, “when the former disease disproportionately affects White children and the latter disproportionately affects African American children,” he wrote.
Penn Medicine CEO Kevin Mahoney shared similar concerns, saying that he didn’t want the ranking to sway them from making the decisions that were best for the community, such as taking over a struggling hospital in a lower-income area.
Rankings and equity
While US News has developed metrics of health equity, they have yet to be fully incorporated into the ranking for adult hospitals. This means that the ranking still isn’t rewarding hospitals with the best equity performance. In fact, “U.S. News’ honor roll hospitals tended to perform worse than other hospitals in health equity,” said US News data analyst Harold Chen, in Becker’s Hospital Review.
The inverse relationship between equity and outcomes reflects a larger problem within our health system. Hospitals are already reimbursed the most for doing elective procedures for privately-insured patients, not for doing preventive care or focusing on chronic conditions in poorer communities. Having hospital rankings reward hospitals for the same thing further incentivizes them to invest in new technology and advertising rather than invest in their surrounding communities. The result is that the hospitals that have the capacity and finances to do lots of complex specialty procedures are often completely inaccessible to low-income patients.
As Dr. Helena Hansen, interim chair of psychiatry and biobehavioral sciences at UCLA, said to STAT News, “the U.S. News rankings celebrate what is essentially a racist two-tiered healthcare system.” If rankings don’t include metrics of equity, they will perpetuate this pattern.
The rankings respond
In response to these criticisms, US News has made some methods updates, such as adding outpatient outcomes metrics to reflect the shift toward more outpatient surgeries, and reducing the weight of the “expert opinion” section, which has been previously denounced as a “popularity contest.” However, the updates did not include a timeline for incorporating equity metrics into their Best Hospitals ranking.
Aside from US News, other institutions in hospital evaluation are starting to take equity into account. For example, the Joint Commission, a nonprofit accrediting agency for hospitals, recently added standards on screening patients for social determinants of health and mandated safety and quality data collection by race and ethnicity. They’ve also added an optional certification program in health equity that requires participating hospitals to designate a health equity officer, collect sociodemographic data on patients and staff to identify hiring disparities, conduct trainings, and more.
Leapfrog, a national patient safety ratings organization, also released a report identifying persistent patient safety outcomes disparities by race, even at hospitals with high grades overall. However, Leapfrog has not yet incorporated data on racial disparities into their hospital ratings.
And last year, the Centers for Medicare and Medicaid Services (CMS) released new metrics for hospitals on health equity to assess hospitals’ commitment to health equity and to encourage them to screen patients for social needs like food insecurity and housing instability.
A ranking that measures what matters
I’d be remiss not to mention the hospital ranking that has measured health equity from the start– the Lown Hospitals Index. Since 2020, we’ve incorporated health equity metrics such as patient inclusivity (measuring how well hospitals care for patients from lower-income communities and communities of color), community benefit (measuring how much hospitals give back to their communities), and pay equity (measuring how much hospitals pay their CEOs compared to other workers).
It turns out, when you include equity, hospital rankings come out way different. Just take a look at last year’s comparison of the top hospitals from US News— most of them struggle to achieve on equity despite having good performance on outcomes. Whereas US News‘ “honor roll” hospitals tend to have worse performance on equity, on the Lown Index honor roll, having good performance on equity is required.
We’re proud to be the first national ranking to incorporate metrics like these, and we’re happy to see that measuring health equity has become a national trend in rankings.
The launch of the full 2023 Lown Hospitals Index rankings is coming soon! Join the Lown Institute for a launch event July 18 as we reveal this year’s most socially responsible hospitals.