Since early this spring, a flood of patients infected with the novel coronavirus has stressed many of the nation’s hospitals to their limits, revealing like never before what’s good, bad, and ugly about our health care system.Check out the complete Washington Monthly hospital rankings here.
On the positive side, we’ve seen extraordinary selflessness and heroism from the people who work in hospitals. Doctors have come out of retirement to lend a hand. Nurses have separated themselves from their families to avoid infecting them. Respiratory therapists, technicians, janitors, patient transporters, and even administrators are literally putting their lives on the line. As of April 7, the Centers for Disease Control and Prevention estimated that COVID-19 had infected 9,000 health care workers and killed at least 27, though the true numbers are undoubtedly far higher. Even some hospital CEOs have done their part by forgoing a few months of pay in order to avoid having to furlough workers.
On the not-so-heroic side, this crisis has also brought news of misbehavior. One major teaching hospital, the University of Pittsburgh Medical Center, continued scheduling lucrative elective surgeries long after the state’s governor ordered hospitals to stop such surgeries so they could prepare for the surge of COVID-19 patients. One uninsured woman in Boston who had symptoms of COVID-19 got a $34,000 bill for her emergency room treatment. Some hospitals have maintained aggressive bill collection practices, dunning working-class patients whose incomes have plunged in the pandemic-induced recession. Still others have threatened to fire workers who speak publicly about the lack of personal protective equipment (PPE) and refused COVID-19 tests for people with symptoms while offering them to the rich and famous.
More than anything, the crisis is driving home the cruel inequities between neighborhoods and the hospitals that serve them. Numerous reports show that black and Hispanic Americans are being hospitalized and dying of COVID-19 at much higher rates than other groups. That’s likely a consequence of several factors, like the fact that they disproportionately work in higher-risk professions like food service, and live in more vulnerable circumstances, such as multigenerational homes.
They’re also being cared for, often, in hospitals with fewer resources. Places like Elmhurst Hospital Center, a large safety net hospital serving a mostly working-class and immigrant population in Queens, New York, struggled to find PPE for its frontline workers as an apocalyptic number of patients descended at the height of the infection. Across the East River in Manhattan, Mt. Sinai, the prestigious teaching hospital on Central Park, was able to procure N95 masks from a hospital in China with private jets owned by Warren Buffett.
These inequities are built into the way hospitals in America are allowed to do business. A majority of them are technically nonprofits, but the largest, most prestigious ones often earn returns that would make a Fortune 500 CEO envious. Mt. Sinai’s operating revenue grew nearly 7 percent in 2019, and it had more than $700 million in reserves. It achieved this bonanza in part by marketing high-margin elective procedures, like cardiac stents, to wealthier patients with good insurance. Prestigious hospitals also stay profitable by not serving their fair share of lower-income patients and people of color—people who may lack insurance altogether and often have multiple chronic conditions, like diabetes, that are not very profitable to manage.
That sort of behavior forces safety net hospitals like Elmhurst to pick up the slack, which typically leaves them struggling financially to find the revenue, personnel, and equipment to do their jobs. An audit a decade ago found that Elmhurst patients had to wait an average of 148 days for routine mammograms, the longest wait in the city.
The current structure of our hospital system doesn’t just reflect the inequities of the American economy, it also helps drive them. Over the last decade, health care costs per capita have risen twice as fast as wages. In fact, a major reason why wages have barely kept up with inflation for decades for most middle- and lower-income Americans is that more and more of their income is being funneled, via payroll deductions, into the health care system. The system’s costs keep rising in part because hospitals have been merging, creating local monopolies with the power to demand higher prices, and indulging in “overtreatment”—that is, performing tests and procedures, like knee arthroscopies, that studies have shown are either completely ineffective or no better than less invasive and less expensive treatments. Overtreatment also puts patients at needless risk of everything from medical errors to hospital-acquired infections to drug mishaps, which together kill as many as a quarter of a million hospital patients each year.
The pandemic has been a great equalizer in one sense: Regardless of which class of patients they serve, hospitals are getting financially creamed because of the high costs of treating COVID-19 patients and a nationwide drop in profitable surgeries. The federal government has responded with more than $100 billion in aid to hospitals. But that will almost certainly wind up just being a down payment. Hundreds of billions more tax dollars will be needed.
Rather than hand that money over with no strings attached, federal lawmakers should treat the bailout as a chance to fundamentally rethink the nation’s entire health system and the role hospitals should play in it. After all, a third of the more than $3.6 trillion we spend annually on health care flows through America’s hospitals—much of it tax dollars, from Medicare payments to research grants to the enormous monetary benefits that come with tax-exempt status, on top of the bailout funds. Taxpayers have a right to demand some accountability for all that money.
If we want to start holding hospitals more accountable for improving their performance, however, we first need a reliable set of metrics to hold them accountable to. Unfortunately, those metrics don’t exist—not in government or the private sector.U.S. News’s honor roll is all brand-name teaching hospitals and features no safety net hospitals. Our list contains a mix.
The most well-known and influential rating of hospital performance, U.S. News & World Report’s “America’s Best Hospitals” list, is certainly not up to the task. More than one-fourth of a hospital’s score on the U.S. News rankings is based on a survey of medical specialists. As such, it is largely reflective of high national brand-name recognition, which is fueled in part by the rankings themselves. Its other metrics focus almost entirely on the outcomes of the patients a hospital admits, paying no attention to a propensity to overtreat or the degree to which it is treating the health needs of the broader population of its community. And the magazine’s rankings have real power. Hospital administrators spend time and money in order to climb up the list, because doing so gives them bragging rights they can use to bring in more well-insured patients. Other rating systems, like IBM Watson Health’s “Top 100 Hospitals,” aren’t much better. If you want to know where to get your hip replacement, these guides do a fine job. If you want to know which hospitals are using their resources wisely to provide quality care to everyone in their communities, they tell you literally nothing.
That’s why the Washington Monthly teamed up with the Lown Institute, a nonpartisan health care think tank, to create our “Best Hospitals for America” ranking. We used data drawn from the Lown Institute Hospitals Index not only to measure how well hospitals care for their patients but also to gauge the contributions hospitals make to the country and their communities. Our rankings use three main criteria. First, patient outcomes: a hospital’s patient mortality, safety, and satisfaction record. Second, civic leadership: the degree to which a hospital treats patients with the same income and other demographics as its surrounding community; how much it contributes in community benefit, from providing charity care to building and operating free clinics; and how much it pays its senior executive compared to its frontline workers. Third, value of care: how much a hospital overuses low-value tests and procedures.
We then created an “honor roll” of 20 hospitals, each of which achieved the rare feat of scoring notably better than average—in the top 45 percent—in each category. We excluded hospitals from the honor roll that were missing data for one or more of the components. For like-to-like comparisons, we also ranked the 50 best major teaching hospitals out of 224 nationally and the 100 best safety net hospitals out of more than 650 nationally.
(For a more detailed methodology, click here. For the full ranking of more than 3,200 hospitals, see the Lown
Institute Hospitals Index. For the backstory on how these rankings came about, see the Editor’s Note here and brief explanatory essay from the Lown Institute here.)
Given our different approach to measuring success, we expected that our lists of top hospitals would look different from U.S. News and other rankings. We had no idea just how different.
Like the Monthly, U.S. News publishes an “honor roll” of its top hospitals. Amazingly, not one of the 20 institutions on the U.S. News honor roll appears on ours. U.S. News’s list is made up entirely of brand-name teaching hospitals, including Mt. Sinai, which it ranks 14th. None of its winners are safety net hospitals. Our honor roll, by contrast, contains a mix of well-regarded (if not necessarily world-famous) teaching hospitals, such as University of Colorado Hospital in suburban Denver; safety net hospitals, like Oroville Hospital in California’s Central Valley; and an assortment of community hospitals of varying sizes whose names almost no one outside their communities has ever heard of—like Mercy Health–West Hospital in Cincinnati, Ohio, and Providence Centralia Hospital in Washington State.
With a couple of exceptions, such as Boston Medical Center, our top institutions are not at the cutting edge of advanced medical research, and they may not be at the forefront of experimental surgical techniques, like those on the U.S. News honor roll. Rather, they are succeeding at something that is arguably more difficult, because so few hospitals manage to pull it off: They are doing a great job, simultaneously, of treating a diverse patient population representative of their communities, healing those patients, and not overtreating them.
The reason it is so hard to strike this balance, as our colleagues at the Lown Institute discovered in the process of putting these rankings together, is that some of the metrics we chose are negatively correlated. For instance, a typical safety net hospital that treats a disproportionate share of working-class and poor patients is likely to have a lower patient outcomes score than a typical major teaching hospital. In some instances, that might be because the former’s medical staff is less skilled. But it might also be because its patients have more severe cases of the conditions—heart disease, say—than the more affluent patients that teaching hospitals are treating with the same conditions. It might also be that the safety net hospital is discharging its patients into environments that are less healthy—a crowded fourth-floor walk-up in Queens, say, as opposed to a five-bedroom home in suburban Scarsdale with a private visiting nurse—so that their post-hospital mortality rates (which we measure) are higher. Based on currently available data, it’s hard to tell.
That is all the more reason to be impressed with the hospitals on our honor roll. Take number one–ranked JPS Health Network, a large, public safety net hospital with more than 500 beds and 40 outpatient clinics in Fort Worth, Texas. JPS is also a teaching hospital, which means it provides graduate-level training to residents, or to doctors who have finished medical school. It has the largest residency program in the country for young physicians going into family medicine, a primary care specialty whose practitioners are in short supply in every community in America. JPS also takes care of a largely Hispanic and black, working-class and poor population, relative to its surrounding community. JPS scores well across all of our categories, ranking in the 83.8th percentile for patient outcomes, the 99.5th percentile for civic leadership, and the 90th percentile for avoiding overuse of low-value care. It sets the standard, in our estimation, of what a great hospital should be.
Contrast JPS to the Mayo Clinic, in Rochester, Minnesota, which sits in the number one slot of the U.S. News honor roll. The Mayo Clinic is world renowned, and for good reason. It provides top-notch specialty care, such as organ transplants, open-heart procedures, and cancer surgery. In fact, people from all over the world fly in for their specialty care. But not only does the Mayo Clinic fail to make our top 20 honor roll, it doesn’t even rank on our list of top 50 teaching hospitals, coming in instead at number 100—that is, the middle of the pack. That’s because, though its patient outcomes score is excellent (99.2nd percentile), it does abysmally on civic leadership (10.6th percentile) and value of care (7.4th percentile). The Mayo Clinic is a great place, in other words, to get a major surgery—as long as you aren’t poor, have excellent insurance, and actually need the surgery.
Ranked 10th on our honor roll and fourth on our major teaching hospital list is the Boston Medical Center, a world-renowned institution affiliated with Boston University Medical School. It also happens to be a safety net hospital, coming in at number two on our best safety net hospital ranking just after JPS Health Network. Boston Medical Center, known locally as the BMC, serves as the city’s largest tier one trauma center, which means it cares for patients who come in with severe injuries, the type that result from things like gun violence and car crashes. Like JPS, Boston Medical Center also cares for a sizable share of Boston’s working-class and poor population.
Less than three miles away from BMC is Massachusetts General Hospital, one of the most renowned research and teaching institutions in the country. Mass General comes in second on the U.S. News honor roll, but doesn’t make our honor roll or our top 50 teaching hospital list, clocking in at 51st on the latter ranking. To be sure, Mass General scores in the 93.7th percentile on patient outcomes, higher than BMC, which ranks in the 69.1st. But again, that may be because Mass General’s “inclusivity” score—a measure of the degree to which it treats patients with the same income and other demographics as its surrounding community—is in the 43rd percentile, whereas BMC scores in the 99.7th.
What Americans should be asking is, why can’t all hospitals be more like JPS or BMC? Shouldn’t every person in this country have access to a hospital that provides high-quality care, welcomes all comers regardless of wealth and insurance status, avoids unnecessary care, and contributes to the health of the larger community?
The next wave of bailouts for the hospital sector would be an excellent time to raise these questions, and to begin passing three sets of policies that will incentivize hospitals to behave better.
First, the federal government needs to get serious about defining what hospitals must do to continue to enjoy the benefits of their nonprofit status—and states, which grant and police hospitals’ nonprofit charters, need to start enforcing those standards. The standards should include some version of the Lown Institute’s inclusivity metric.
Second, we need to move to a hospital payment system in which prevention, primary care, and effective management of disease are better compensated, while payments for specialty care fall more in line with prices paid in other wealthy nations. One way to do this would be to readjust Medicare and Medicaid reimbursement rates, as well as other public subsidies, to better reward providers for community-focused health care. Even better would be to create a system of administered prices plus global budgeting for hospitals and insurers, public and private, as the Washington Monthly has recommended.
Third, if we ever want to get health care costs under control, we need the federal government to require insurance companies to disclose the actual prices they pay for individual procedures at individual hospitals—something that, bizarrely, providers and insurers both consider a “trade secret.” We also need those companies’ claims data—which includes information about individual patients’ various illnesses and what was done during their hospital visits—in order to gauge the quality of a particular hospital’s care and, together with the price data, calculate its value.
In addition to mandating the release of commercial price and claims data, the government could help outfits like the Lown Institute and the Washington Monthly do their jobs of evaluating hospital performance by requiring the release of other data in better form. For instance, the reports that nonprofit hospitals are required to send the Internal Revenue Service documenting the “community benefit” investments they are making in order to justify their tax-exempt status are often incomplete, and the IRS lets hospitals get away with it. The agency also permits hospitals to claim several kinds of spending as a community benefit that shouldn’t count—like the costs of residency programs, which the federal government already underwrites. It would also be nice if the government standardized requirements for disclosure of hospital CEO pay—right now it takes a ton of sleuthing to figure that out. (Hmm, wonder why?)
Even with these gaps in and difficulties with the data, we and the Lown Institute are confident that our new rankings reveal important realities about the performance of the nation’s hospitals. We also believe that they set a better standard for what we should expect from our hospitals than any other rating system out there. That includes U.S. News, whose rankings both reflect and incentivize much of what is wrong with the current health care system. Hospitals that do well on the U.S. News rankings are ones that excel at lucrative specialized treatments and procedures, period. The ranking gives them no incentive to control overtreatment or serve patients of modest means—in fact, hospitals do better if they keep such folks out.
Imagine, however, if hospitals were motivated to rise in our rankings. They would compete to bring in patients from all levels of society, not just the well insured. They would find ways to get their staffs to stop performing unnecessary procedures and tests. They would try to reduce the pay differential between hospital workers and chief executives. (Do we really want our hospital workers earning so little that they feel they can’t afford to stay home when they’re sick, especially during a pandemic?) And they would put more of their earnings into improving the conditions that affect the health of their communities.
If more hospitals had done these things before the pandemic, how many Americans might have been in healthier shape to fend off the virus, or survive it if they did get it? Of course, it’s impossible to say. But it’s not impossible to use this moment to remake our health care system so that next time we don’t have to ask the question.
Research assistance was provided by Cole Garcia.