Hospital performance trends reveal inequities in the system

The Lown Institute recently released their ranking of America’s most socially responsible hospitals for 2022. Hospitals at the top of the ranking prove that it’s possible to provide excellent patient outcomes, prioritize equity, and avoid overuse all at the same time. But just because it’s possible does not mean it’s easy.

Only 66 hospitals out of more than 3600 ranked received all “A” grades on equity, value, and outcomes — just 2% of the total. Why do so few hospitals get top grades across the board? The answer has to do with systemic inequities within our healthcare system and how they drive hospital behavior.

Outcomes vs Equity

Since we started the Lown Hospitals Index in 2020, we’ve noted an inverse relationship between outcomes and equity — hospitals with the best grades on outcomes tend to do worse on equity, and vice versa.

This year is no different. Only 114 hospitals (3% of all hospitals ranked) received A grades on both equity and outcomes. Hospitals with “A”s on equity tend to have worse performance on outcomes metrics than hospitals with “C”s or “D”s (see table below). This pattern is especially acute comparing average rank on clinical outcomes, which includes mortality and readmissions. Hospitals with better outcomes grades have worse performance on equity metrics on average, particularly when it comes to pay equity (how much hospitals pay their CEO compared to other workers) and patient inclusivity.

Table: Comparison of average rankings on the Lown Hospitals Index for hospitals by Outcomes and Equity

	Number of hospitals	Equity rank (average)	Pay equity rank	Community benefit rank	Inclusivity rank
Hospitals with “A”s in Outcomes	1038	2219	2333	1976	1916
Hospitals with “C”s or “D”s in Outcomes	913	1752	1481	1855	1529
	Number of hospitals	Outcomes rank (average)	Clinical outcomes rank	Patient safety rank	Patient satisfaction rank
Hospitals with “A”s in Equity	754	2112	2154	1194	1986
Hospitals with “C”s or “D”s in Equity	1623	1645	1588	1076	1674

The same pattern occurs when looking at the top hospitals for outcomes and equity. Among the top 10 hospitals for outcomes on the Index, none received an “A” in equity. And among the top 10 for equity, none received an “A” in outcomes (see tables below).

Outcomes rank	Hospital	State	City	Equity grade
1	Mayo Clinic	FL	Jacksonville	D
2	Mayo Clinic Hospital Rochester	MN	Rochester	C
3	Avera Sacred Heart Hospital	SD	Yankton	C
4	Virginia Mason Medical Center	WA	Seattle	C
5	Mayo Clinic Health System Eau Claire	WI	Eau Claire	C
6	Ascension St. Vincent Carmel	IN	Carmel	C
7	Pali Momi Medical Center	HI	Aiea	C
8	University of Utah Hospitals and Clinics	UT	Salt Lake City	C
9	Legacy Salmon Creek Medical Center	WA	Vancouver	B
10	Presbyterian St. Luke’s Medical Center	CO	Denver	B

Equity rank	Hospital	State	City	Outcomes grade
1	Metropolitan Hospital Center	NY	New York	B
2	Woodhull Medical and Mental Health Center	NY	Brooklyn	B
3	University Hospital	NJ	Newark	C
4	Harlem Hospital Center	NY	New York	B
5	St. Charles Madras	OR	Madras	B
6	Brownfield Regional Medical Center	TX	Brownfield	C
7	Temple University Hospital	PA	Philadelphia	B
8	Prosser Memorial Hospital	WA	Prosser	B
9	Mercy Hospital Logan County	OK	Guthrie	B
10	Medina Regional Hospital	TX	Hondo	C

Separate and unequal

The inverse relationship between outcomes and equity on the Lown Hospitals Index reflects our 2-tiered healthcare system: Those with private insurance have greater access to prestigious, well-resourced hospitals, while those with public insurance or no insurance often go to safety net hospitals that struggle to reach the same quality standards.

The divide stems from the backwards way in which we pay hospitals. Hospitals get paid the most to perform high-tech elective surgeries for patients with private insurance, but barely break even on preventive or routine care for patients with Medicare or Medicaid. This means hospitals have to attract a certain number of privately-insured patients to succeed financially, which leads to them to things like expand their practices to the suburbs despite greater need in the city; invest in unproven but attractive technologies like proton beam machines; and turn their campuses into glittering cities to draw patients from around the world.

“My husband calls [the Cleveland Clinic] the Emerald City because at night it lights up down there with the glass and the structures of the buildings. As you can see, they’re building all around us … they’re making their own world.”

Nora Brown, Cleveland resident, WKSU

At the same time, safety net hospitals that currently care for a disproportionate number of uninsured and publicly insured patients get paid less to care for these patients and as a result run on much lower margins compared to other hospitals.

Our separate and unequal hospital system creates disparities in access and quality of care. For example, Black and Indigenous individuals are deeply underrepresented in clinical trials of new cancer drugs, in part because they have less access to the hospitals that run these studies. Lower-quality care at some safety net hospitals also contributes to higher rates of COVID-19 mortality and life-threatening birth complications. 

How the system must change

For more hospitals to succeed on both outcomes and equity, we need a healthcare system that rewards hospitals for taking care of everyone in their community and financially supports the hospitals that are already doing so.

Our 2-tiered reimbursement system is a legacy of racism. People of color make up about 60% of those covered by Medicaid*, but only 35% of those with employer-sponsored private insurance. If we want everyone to have equal access to hospital care, there should be no difference in the reimbursement rates for those with public versus commercial insurance. If that sounds radical, consider that Maryland has had an “All-payer” rate system since the 1970s, in which hospitals are paid similar rates for each patient regardless of insurance status.

We have to not only make high-quality hospitals more accessible, but improve the quality of hospitals taking care of the most medically complex patients. Unfortunately, many of the “pay-for-performance” models that have been implemented are further penalizing safety net hospitals financially, which may make it even harder for them to catch up. Policymakers should target America’s most equitable hospitals for investment and assistance, so that the patients they serve can get the best care possible.

We need many other hospitals to join those at the top who are providing excellent patient outcomes for all in their community. While holding hospitals accountable for their performance on equity is essential, we also need substantive policy changes around payment models and hospital incentives to transform the system.

*This blog was edited to correct an error. People of color make up about 60% of Medicaid patients, not 85%.