Last June, in the wake of the police killings of Breonna Taylor and George Floyd, among others, and amid nationwide calls for sweeping racial justice measures, hospitals were among the many institutions that issued statements vowing to root out racial inequity and work toward antiracist practices. “We must move from rhetoric to action to eliminate the inequities in our care, research, and education of tomorrow’s doctors… We can no longer be bystanders,” the American Association of Medical Colleges wrote on June 1, 2020 in a statement that decried racism and the racial health inequities exposed by the coronavirus pandemic.
But as time goes on, will hospitals and health systems actually make substantial changes? How will health institutions be judged on progress toward promises made in the apex of summer 2020's Black Lives Matter protests?
A group of Boston doctors believes one answer is to tie hospital rankings to health equity metrics. In a piece published in March in Health Affairs blog, seven doctors representing four of Boston's major health institutions are calling for metrics specifically focused on health equity to be baked into influential hospital rankings such as U.S. News and World Report’s annual “Best Hospitals” and “Best Children’s Hospitals.”
“It's important to have ways to hold people to account for these commitments that they're making,” says Crandall Peeler, MD, a Boston Medical Center ophthalmologist and one of the blog post's authors.
Why hospital ranking systems matter
While mainstream hospital rankings are geared toward an audience of patients and families seeking the best possible care, Peeler says hospitals also take them seriously.
“Hospital systems care a lot about rankings, because those that score well in certain areas or across the board use those rankings to recruit staff and trainees and to advertise their programs to attract more patients,” he says. “So, it's something that the general public looks at closely, and hospitals care a lot about how they stack up against other hospitals.”
Peeler is gratified that peers from four major hospitals — BMC, Boston Children’s Hospital, Massachusetts General Hospital, and Brigham and Women’s Hospital — are speaking together to call for accountability, especially as it means more scrutiny on the quality of their own institutions.
“Even those who always get really high rankings don’t want to just rest on their laurels,” he says. “We wondered, what can we do, or how can we speak out to say that we're really dedicated to this and we want to be held accountable? And across the board, it was, "These are things that we believe in, and our hospitals believe in, and we want to be measured on these issues."
What are the current hospital ranking metrics?
Hospital rankings today typically include three broad domains, Peeler says: health system structure, process, and outcomes.
Health system structure covers how hospitals are financed and where they direct resources, including, for instance, how many MRI scanners they have or the density of nursing staff in intensive care units.
Process focuses on how patients are diagnosed and what types of treatments they receive. this domain includes information gleaned from patient satisfaction surveys.
Rankings of outcomes, based on data from the federal Centers for Medicare & Medicaid Services, assess risk-adjusted mortality. “So if somebody comes into my hospital with a heart attack, the ranking agencies can see, what is the survival rate or mortality rate for that condition?” Peeler explains.
What would health equity metrics look like?
What’s not included in the major, mainstream ranking systems are specific equity measures. There's been a little evolution in that direction: U.S. News & World Report in recent years has attempted to take into account patient socioeconomic status by adding a weighting formula for the percentage of Medicare- and Medicaid-eligible patients a hospital sees. In this way, the rankings are less apt to penalize hospitals with a high proportion of low-income patients if their outcomes, given the added complexity of their patients’ conditions, are worse than hospitals serving only privately insured patients.
Peeler calls this weighting system a step forward but still a proxy — a vague acknowledgment that poverty is a social determinant of health. What he and others want to see are direct equity metrics. And strides are being made in defining some of these. The authors applaud a joint effort underway by the Bloomberg American Health Initiative, the Johns Hopkins Center for Health Equity, and IBM Watson Health to identify metrics that would measure “the impact of hospitals on community health with a focus on equity.”
Some examples: A hospital would score higher if it had a hospital-based violence prevention program, had an ER-based opioid use disorder treatment program, or funded a community-based hypertension control program that could help address conditions before they reach the point where patients need hospitalization. In addition, rankings would include non-patient-facing metrics, such as achieving diversity in hospital boards and management and offering living wages and childcare to all employees.
The new metrics devised by the Bloomberg/Hopkins partnership may soon be part of the Fortune/IBM Watson Health 100 hospital rankings system. Some other new ranking systems are delving into hospitals' community-minded policies.
But for equity metrics to have a real impact, the Boston doctors argue, they must be part of all mainstream rating systems — including the influential U.S. News and World Report annual rankings.
What is the potential impact of holding hospitals accountable?
The use of equity metrics in ranking systems could have a real effect on improvements nationwide in hospitals' equitable delivery of care and hiring. Peeler makes an analogy to standardized tests for high school achievement. High-stakes assessments spur schools, for better or worse, to “teach to the test” and boost performance in whatever subjects are measured. In the same way, hospitals would have strong incentives to enact changes to garner the best possible scores, given the impact of rankings on their reputation.
“A lot of hospital systems around the country have said they were going to commit themselves to more equitable delivery of healthcare,” Peeler says. “By adding health equity metrics to the mainstream ranking systems, there'll be an even greater motivation for healthcare systems to ‘walk the walk’ after they've talked the talk.”