US News may add health equity to rankings: Why it took so long, and what analysts learned in the process

U.S. News & World Report — known for its healthcare rankings, including those that compare hospitals and physicians — has formulated a way to measure hospitals' health equity. And it may eventually be included in the publication's ranking methodology. 

Those involved with the project told Becker's this potential change has been in the works for years, and they hope the measures will incentivize hospitals to prioritize health equity. 

 

21 years in the making 

U.S. News' chief of health analysis, along with two of its health data analysts, published an article Oct. 18 explaining the measures in the Journal of the American Medical Association. The article references a 2001 report, "Crossing the Quality Chasm," which identified six domains that affect health system quality, with equity being one of them. All the domains — safety, efficacy, efficiency, timeliness and patient-centeredness —  other than health equity have been woven into hospital rankings, the article's authors said. 

There are several reasons why 21 years passed between "Crossing the Quality Chasm" and U.S. News' own adoption of equity metrics, the article's authors told Becker's

Equity has not always been aligned with health organizations' financial interests in a fee-for-service world, according to Ben Harder, chief of health analysis at U.S. News. It is easier to observe inequity than to place blame for it, he said, as local governments and structural racism shoulder some accountability for the care gaps seen today. This has made it difficult to determine how much responsibility health systems should assume for improving equity.  

Plus, health equity is difficult to measure. 

"We work primarily with Medicare data," Harold Chen, health data analyst for U.S. News, told Becker's. "For example, if we wanted to look at health equity along the lines of disparities for queer, trans people. That's really difficult with the data we have. We just don't get that kind of information with what we have." 

But recent events have catalyzed conversations around health equity, according to Tavia Binger, senior health data analyst for U.S. News. Ms. Binger received her master's in public health and remembers having conversations about equity in the classroom. However, after COVID-19 and the "racial reckoning" of 2020, she has seen these discussions extend to the public. 

"On some level, it's sort of like a snowball rolling down a hill," Chen said. "The more voices and people that speak up and say, 'This is something we should address,' the more ability we also have to address it."

These conversations began in U.S. News circles several years ago, Mr. Harder said. A former colleague said during her hiring process that the organization should measure health equity. Discussions ensued, culminating at U.S. News' annual conference in 2019. At a standing-room-only workshop, healthcare leaders and U.S. News employees fleshed out ways to measure health equity with the data available. 

 

How to measure equity

Over the next three years, U.S. News teams developed three "domains" to measure health equity: access, outcomes and social determinants of health. When combined into a summary score, these domains provide an "equity metric" for hospitals. 

To measure access, analysts look at the representation of socially vulnerable patients at different hospitals, then compare it to the population of that hospital's community, Ms. Binger said. Sometimes, hospitals are serving far fewer — or far more — minority patients than live in their service area. 

When evaluating outcomes, U.S. News looked at data for procedures rated in their annual "procedures and conditions" publication, Ms. Binger said. For each procedure, they examined 30-day unplanned readmissions for both Black and white patients to identify any differences in readmission risk.

U.S. News' social determinants of health metric looks at the amount of charity care a hospital provides. Analysts look at how much of a hospital's revenue is used to care for uninsured patients. Ms. Binger said this measure zeroes in on the uninsured because individuals in this population tend to delay care or not seek it out at all, and the other measures do not address this population as accurately. 

Although the metrics are scored separately, they interact with and affect one another, Chen said. If uninsured patients know a hospital provides little charity care, they may not go there, which could affect access and outcomes.

 

Exposing a segregated system

U.S. News' honor roll hospitals tended to perform worse than other hospitals in health equity, Chen said. And equity differences between hospitals in the same community —  and even the same health system — can be stark, Ms. Binger said. 

"What we're really seeing is the ongoing segregation of healthcare, even though segregation in healthcare has been illegal for more than 60 years," Mr. Harder said. 

U.S. News rankings have historically been produced to help patients make informed decisions on where to seek care. However, a health equity ranking is more nuanced. Many groups most affected by the measures, such as certain racial or ethnic groups and low-income patients, have less say in where they get care than their white, wealthy counterparts. They could lack transportation and broad insurance coverage and may lack the health literacy necessary to navigate a complicated system. 

Mr. Harder said patients can still benefit from health equity rankings, which can guide them toward a hospital where they feel welcome. 

However, there is a facet of health equity reporting designed to "move the system," Mr. Harder said. U.S. News aims to include equity measures in its high-profile rankings soon. Hospitals and health systems pay attention to U.S. News' rankings, and having an independent arbiter could incentivize them to make health equity a priority, he said. 

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