A Hospital Ranking That Makes Sense

Inside the Washington Monthly’s 10-year effort to redefine what “best” means in healthcare.

Ten years ago this fall, two dear friends of mine, the journalists Shannon Brownlee and Phillip Longman, joined me at the Washington Monthly offices to hash out an idea: creating a ranking of the nation’s hospitals to compete with U.S. News & World Report’s “Best Hospitals” list, just as the Monthly had done with its alternative college guide.

Check out the complete Washington Monthly hospital rankings here.

The three of us had worked at U.S. News in the 1990s, and Shannon and Phil had recently published seminal books about health care quality and cost that had been road-tested as articles in the Monthly. So we had an inside sense that U.S. News’s hospital rankings suffered from the same basic design flaws as its college rankings. Both elevated (and still do) prestigious institutions that primarily cater to the elite at the expense of those that serve the rest of us, using metrics that are as dubious as they are destructive. Their hospital rankings focus almost exclusively on expensive specialized treatments and surgeries, like organ transplants. Meanwhile, they ignore the bulk of what most hospitals do, which is treating patients for more routine ailments, like broken bones and pneumonia. And they rely heavily on a survey of medical specialists, effectively boosting the ratings of hospitals with high national brand-name recognition, while downgrading or ignoring others that score better on measures of cost and value. The latter failing is especially damaging, given that health care costs for most privately insured Americans have been rising for years at twice the rate of wages. 

Taking on U.S. News made sense to us because its rankings have real power. Hospital administrators all over the country devote considerable energy to climbing them—and then bragging about it on expensive billboard ads—because doing so helps bring in more well-insured patients. Yet such behavior also fuels the profligate and inegalitarian tendencies of our health care system.

We spent weeks back in 2010 looking into the specifics of building a robust alternative hospital ranking and quickly realized that it would take considerable funds, especially for computational expertise we lacked. When we couldn’t find a funder, we shelved the project. But whenever we’d get together after that—often over dinner at each other’s homes—we’d wind up excitedly talking about reviving the idea. It was our data journalism white whale.

Then, a couple of years ago, we had a breakthrough. Shannon was by then working at the Lown Institute, a health care think tank that was pioneering a new machine-learning algorithm to assess hospital care quality and overuse. She and her colleague Dr. Vikas Saini saw a way to apply the tool to the task of ranking hospitals, and the Lown board agreed to fund the effort. They then hired a crack team of data researchers and empaneled an expert advisory board (on which I was the least qualified member) to provide feedback to the data team, a process that took the better part of two years. After two more months of biweekly Zoom calls with the Monthly’s editors, Lown completed the rankings we’re debuting in this issue.

Paul, Shannon, and PhilThough the 10-year wait was frustrating, it had a couple of upsides. First, it delayed publication of our rankings until a moment—the middle of the COVID-19 crisis—when citizens and policy makers are more aware than ever before of the public service role America’s hospitals play. This is very un-Monthly-like. Typically, the magazine tries to focus its reporting on subjects that the nation isn’t paying attention to but should be—like the growth of monopoly capitalism, or the promise of voting by mail, ideas we were a lone voice in covering for nearly a decade before they became popular topics of conversation. As Phil likes to say, we write about “solutions to problems people don’t know they have.” But with this issue, we’re actually on top of the news. What a concept!

Second, the long deferment gave us time to sharpen our thinking about the key role hospitals play—or in many cases don’t play—in serving the health care needs of the less well off in their surrounding communities. This is a subject that cannot be morally ignored now that we’ve seen the disproportionately high rates of COVID-19 infection and death among black and Hispanic Americans. The Lown Institute devised smart new ways of assessing the degree to which hospitals behave equitably, along with their clinical outcomes and record of curbing overtreatment. This gave us a set of metrics that are very different from U.S. News. Rather than rate hospitals narrowly—on how they do with complex surgeries regardless of the amount they spend or who they treat—the Monthly rates them broadly: on how well they save lives, save money, and serve everyone. 

Not surprisingly, the results of our rankings are quite different, too. All of the names on U.S. News’s top 20 “honor roll” are famous teaching institutions, like the Mayo Clinic and Johns Hopkins Hospital. Not one of those institutions made it onto our top 20 list. Instead, ours is comprised of a mix of teaching, safety net, and community hospitals whose names—Mercy Health–West Hospital in Cincinnati, Ohio; Providence Centralia Hospital in Washington State—are largely unknown outside their local areas. While they might not be on the cutting edge of medical research, they are arguably doing something much harder, because so few hospitals can manage it: They are taking in a diverse patient population, healing those patients, and not overtreating them. 

We think every American ought to have access to institutions like these. And if the hospital sector needs another bailout because of the pandemic—as it almost certainly will—we hope lawmakers, inspired by our rankings, will demand some accountability for all that money. We’d also like to see Washington mandate that hospitals and insurance companies make public the prices paid for specific procedures—which, amazingly, they don’t—and crack down on hospitals that abuse their nonprofit status by acting like predatory for-profit monopolies.

Can an alternative hospital ranking from a small magazine really have a substantive impact on America’s health care system? Well, there’s no doubt that over the past decade and a half our alternative college rankings have helped shift the national policy conversation about higher education—from a reverential preoccupation with the exclusive, expensive universities that dominate the U.S. News list to a greater focus on colleges that provide quality degrees at reasonable prices to students of modest means (and do well on our rankings). So, yeah, we think we can make a difference.

Elsewhere in this issue of the magazine you’ll find another project we hope will have a positive impact on the world—in a more modest if no less personal way. It is an announcement of the finalists and winners of the Kukula Award for Excellence in Nonfiction Book Reviewing. 

The award, new in 2020, is named for the late Kukula Kapoor Glastris, the magazine’s longtime and beloved books editor (and my wife of 31 years). After she passed away, three years ago—from, of all things, a respiratory illness—my kids and I decided we wanted to honor her memory by creating some kind of award for a cause she believed in. We quickly settled on a prize for nonfiction, public affairs–oriented book reviews—the kind that Kuku devoted herself to commissioning and editing. 

Amazingly, no such prize existed, despite the vital role nonfiction book reviews play in the ecology of journalism. As a practical matter, they transmit hard-won reporting, research, and ideas to policy makers, influencers, and plugged-in citizens who aren’t remotely able to read more than a tiny fraction of the important books released each year. At their most elevated, they provide writers with a platform to develop their own ideas.

As with the hospital rankings, it took longer than we expected to launch the Kukula Award; we managed it only thanks to the generous support of friends and family and long hours of work from my colleagues. We received more than 100 entries from scores of publications large and small. An esteemed panel of judges joined me in reading through them, and—with some difficulty, because the quality of the submissions was generally quite high—we chose the finalists and winners. The two winners each received a prize of $1,000.

After years of financial distress, media outlets are less and less inclined to devote the resources necessary to publish these kinds of reviews—or, at any rate, to pay writers enough to do the job well. But the positive response we got from publications and the overall excellence of the submissions shows that quality nonfiction book reviewing is not yet a lost art. Our hope is that the Kukula Award will inspire more publications to practice it.

Kuku had a special talent for this kind of work—a combination of a fine literary ear and an expansive view of the kinds of books the Washington Monthly should review. If it were up to me, we’d have mostly focused on policy tomes, but she insisted on also commissioning reviews of books on everything from history and religion to pop culture. In celebration of the award, we’re publishing an expanded edition of our book review section in this issue. It, too, covers an eclectic range of subjects—from the psychology of boredom to the capacity of animals to create culture. My heart is filled with joy to know that the young Monthly editors who chose the books and commissioned and edited these reviews are channeling Kuku’s spirit. 

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Paul Glastris

Paul Glastris is the editor in chief of the Washington Monthly. He was an editor at the magazine from 1986 to 1988.