U.S. News & World Report (USN) has developed a “health equity” ranking it may include in its annual ranking of best U.S. hospitals.
The ranking, titled “Best Hospitals: Health Equity Measures,” is based on racial disparities in unplanned readmission, charity care provision for uninsured patients, community residents who accessed care at a ranked hospital, and preventive care for black residents in the community.
In an October 28 article in Becker’s Hospital Review, USN editors admitted health equity is difficult to measure accurately and to assign the correct level of responsibility to health care providers.
“We work primarily with Medicare data,” said Harold Chen, a health data analyst for USN. “For example, if we wanted to look at health equity along the lines of disparities for queer, trans people [sic]. That’s really difficult with the data we have. We just don’t get that kind of information with what we have.”
Tavia Binger, a senior health data analyst, reportedly told Becker’s COVID-19 and the “racial reckoning” of 2020 “catalyzed conversations around health equity.” Becker’s did not directly quote Binger.
The criteria for the rankings have come under criticism as vague and representing factors beyond the reasonable control of the ranked hospitals. The term “community,” for example, appears to be undefined within the published methodology, and it is unclear how a hospital is supposed to regulate charity to justify the charity care metric.
Politics and Subjectivity
USN’s equity rankings are based on highly subjective and politically charged criteria, says Matt Dean, a senior fellow for health care policy outreach at The Heartland Institute, which co-publishes Health Care News.
“When dealing with social determinants of health, how you look, where you live, and how much money your parents make may impact your health, but they don’t determine it,” said Dean. “Public health experts often get this wrong. Disparities are real, and we should work to make sure that we eliminate upstream drivers of those disparities. However, the thorny root causes are more difficult to tackle than the politically expedient fallback positions of the ‘demographics is destiny’ caucus who seek to impose identity politics on your medical chart.”
Dean has also criticized the inclusion of codes now being used in Electronic Health Records (EHR) labeled “Social Determinants of Health.”
The codes include what Dean says are highly subjective criteria such as inadequate housing, housing instability, lodgers and landlord problems; unwanted pregnancy, multiparity, and discord with counselors; and stress on the family caused by the return of a family member from military deployment.
Information vs. Determination
Collecting information about disparities is a good idea as long as analysts recognize all treatment should be tailored to the individual, says Merrill Matthews, Ph.D., a resident scholar with the Institute for Policy Innovation.
“On the one hand, I don’t see a problem at all with researchers looking at the questions raised for informational purposes,” said Matthews. “It’s completely appropriate to ask if certain racial minorities have worse outcomes, or whether the data show that certain racial minorities were treated with X while others were treated with Y.”
There are many explanations for less-than-optimal outcomes, but racial bias has little to do with it, says Matthews.
“For example, let’s say there is a homeless minority patient with a substance abuse problem who may not be up to following a medical regimen,” said Matthews. “The standard of care is to provide pills to be taken over several days. The second-best option is a shot given while he is at the hospital. So, the doctor gives him a shot. That decision has everything to do with providing the best care appropriate to this specific patient who may be unlikely to reliably take oral medication, but a ranking might see it as substandard.”
A focus on race is of little value in evaluating health care, says Matthews.
“It strikes me as very unfortunate that the media and medicine, in general, are taking this equity turn,” said Matthews. “Ironically, most hospitals I am familiar with, especially in the cities, are heavily staffed by minorities who are providing the care.”
Concerns: Corruption, Control
Robert Graboyes, an economist and president of RFG Counterpoint, LLC, says equity rankings of hospitals could have some very negative effects on the delivery of health care.
“The Health Equity Measures (HEMs) document is troubling because, one, ‘equity’ is now a shapeshifting catchall inviting politicization and racialization of health care; two, HEM components are arbitrary and subjective; and, three, HEMs will encourage hospitals to act in ways that improve rankings while denigrating care—perhaps incentivizing corruption,” said Graboyes. “[Finally,] four, HEMs inevitably rank hospitals in part on variables over which they have little or no control—such as patient behavior.”
There are racial disparities in health, says Graboyes.
“In ‘Tempering Systemic Racism in Healthcare,’ I said that slavery and Jim Crow did terrible damage to African Americans’ health and that vestigial effects of that legacy still persist,” said Graboyes. “But I also said, ‘Many of the policy prescriptions aimed at rectifying these patterns fail to consider the magnitude of their present-day impact, the efficacy of proposed solutions, or the tradeoffs with other societal concerns.’
“’U.S. News & World Report’s Best Hospitals: Health Equity Measures’ will likely worsen those problems,” said Graboyes.
Kevin Stone (firstname.lastname@example.org) writes from Arlington, Texas
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This article was updated on December 6, 2022.