BOSTON, MA – The Lown Institute, a healthcare think tank, has released the seventh edition of its Shkreli Awards, given each year to perpetrators of the most egregious examples of profiteering and dysfunction in healthcare. The “winners” are chosen with the help of a panel of judges made up of health policy experts, clinicians, journalists, and patient advocates. The awards are named for the infamous “pharma bro” Martin Shkreli, known for obtaining the manufacturing rights of the antiparasitic drug Daraprim and marking up its price by over 5,000 percent.

“When you see all these stories in one place, they stop being anecdotes and start to tell a bigger story,” said Vikas Saini, MD, president of the Lown Institute. “The need for more fairness and integrity in U.S. healthcare couldn’t be clearer.”

2023 Lown Institute Shkreli Award Winners

1. Columbia fails to stop OB-GYN from sexually assaulting patients despite years of complaints
2. Commonspirit nonprofit system pays CEO $35.5 million salary
3. Pharma claims Medicare drug price negotiation violates their constitutional rights 
4. Hospitals partner with private equity to offer medical credit cards
5. Vascular doctor allowed to keep practicing despite discipline in a dozen states 
6. GSK markets Zantac for decades despite potential carcinogenic compound 
7. Any narrowed artery seems a fair target for this alleged coronary stent king
8. Hospitals allegedly “dump” sick, homeless patients on the street
9. Physician payments help medical device maker test experimental products on poor, patients of color
10. Hospital threatens to ship expensive, comatose patient out of the country

A complete list of winners with descriptions, sources, and judges’ comments is available at the Lown Institute website.

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Join Lown Institute president Dr. Vikas Saini and guest panelists, award-winning author Harriet Washington and professor and activist Dr. Victor Montori, on Tuesday, January 9 at 1 p.m. ET for a countdown and discussion of this year’s winners.

About the Lown Institute

​​The Lown Institute is an independent think tank advocating bold ideas for a just and caring system for health. We envision a healthcare system focused on what’s best for people, like hospitals caring for those most in need, patients living without fear of financial distress, and health professionals finding joy in their roles. The Lown Hospitals Index, a signature project of the Institute, is the first ranking to assess the social responsibility of U.S. hospitals by applying measures never used before like racial inclusivity, avoidance of overuse, and pay equity.

Contact

Aaron Toleos, Lown Institute, (978) 821-4620, atoleos@lowninstitute.org

The post PRESS RELEASE: Biggest healthcare fails of 2023 named in 7th annual Shkreli Awards appeared first on Lown Institute.

#1 Review financial assistance and collection policies

Does your hospital allow patients to be sued for medical debt? What about denying nonemergency care for patients with outstanding debt? Knowing your hospital’s financial assistance and collection policies can go a long way toward improving social responsibility.

All nonprofit hospitals are required to have a policy around financial assistance outlining who is eligible for free and discounted care and how they can get it. Most also have a collections policy that shows what “extraordinary collection actions” the hospital is allowed to take if patients don’t pay (like garnishing wages, suing patients, or sending debt to collections).

However, the extent to which hospitals provide free and discounted care varies widely across the country. In most states, there aren’t strict rules about who should be eligible for assistance, so it’s up to hospitals to create their own policy. Hospitals also differ in the collections actions their policy allows them to take, with some allowing for legal action, reporting debt to collection agencies, and denying nonemergency care for patients with debt.

For hospitals looking to boost their financial assistance ranking on the Lown Hospitals Index, there may be room for improvement in their policies. Hospitals should examine their policies with the following questions in mind:

• Are the eligibility requirements broad and generous?
• Are patients being adequately screened for eligibility?
• Is the application short and easy to understand?
• Are there additional asset tests or residency requirements?
• Are aggressive collection actions allowed?

Reviewing these policies can help hospitals understand where they could expand eligibility or streamline the process to get aid to more needy patients.

#2 Invest in the social drivers that affect upstream health 

Clinicians know that most of what determines their patients’ health happens before patients even step foot in the hospital. Things like environment, education, neighborhood safety, housing, and nutrition make up the social drivers of health. Hospitals and healthcare systems can make a huge impact on community health by investing in these factors, even if they’re outside the hospital walls.

Some hospitals have been incredibly innovative in their programming around social drivers of health, including:

• Helping patients pay their utility bills
• Offering free food from food pantries 
• Investing in affordable housing
• Supporting the local economy through local contracting and hiring

On the Lown Index, we measure hospital spending on community investments like these. (See which hospitals are already at the top in your state!)

#3 Become champions for high-value care 

Overuse of medical services with no or little clinical benefit is unfortunately prevalent at U.S. hospitals. A recent report from the Lown Index found that hospitals delivered nearly 230,000 unnecessary coronary stents to Medicare patients from 2019-2021.

There are many things that hospitals can do to protect their patients from exposure to harm and unnecessary cost. For example, when Children’s Hospital of Colorado found out they had a very high rate of CT scan for abdominal pain (which is not recommended by pediatric specialty organizations), they created a plan of action. They implemented a new protocol to get surgeon consultation in the ER before a CT scan is ordered, to decide whether or not patients were at high risk of appendicitis. Within two years, the hospital cut its rate of these CT scans from 45% to 10%.

Hospitals will soon be able to evaluate their CT radiation dose compared to their peers, using CMS’ new metric on radiation quality. For hospitals that are using too high of a dose, they can undertake initiatives to educate clinicians about reducing their dose to avoid exposing patients to unnecessary harm. 

#4 Evaluate new AI tools with an eye toward equity and overuse

Artificial intelligence (AI) tools are taking off in health care, and hospitals are no exception. AI tools have the potential to improve patient outcomes, reduce administrative burden, and even improve health equity. For example, a recent study found that a new AI algorithm has the potential to identify knee pain in Black patients with osteoarthritis more accurate than radiologists. 

However, experts are also sounding the call about the potential for AI tools to exacerbate existing patterns of racial inequity and overuse in health care. For example, a study of AI diagnostic algorithms for chest radiography found that underserved populations (which are less represented in the data used to train the AI) were less likely to be diagnosed using the AI tool. And a Lancet study testing AI breast cancer screening found that AI-supported screening detected nearly double the number of (DCIS) low-grade cases than standard screening. 

Given these concerns, hospitals should take steps to ensure that their implementation of AI tools is socially responsible. Here’s how some hospitals are already doing this:

• NorthShore – Edward-Elmhurst Health and AVIA are working together to develop a generative AI plan for healthcare systems that focuses on the risks and opportunities of AI as well as guidelines to monitor their usage and effects.
• Hospital systems like CommonSpirit and Penn Medicine are collaborating with health systems and other organizations to screen for, identify, and eliminate biases within EHRs. 
• Houston Methodist Hospital created iBRISK, a breast cancer risk assessment tool supported by AI. iBRISK takes into account patients’ demographics and medical history before recommending future diagnostic testing. By targeting screening toward patients with the highest risk, we improve the chance of benefit from screening.

#5 Prioritize equitable pay for employees 

It’s no secret that a happy, healthy staff makes for better patient care. Improving employee satisfaction is easier said than done, but ensuring equitable pay for all employees is a good start. 

Compared to other nonprofits, hospitals are outliers in terms of how much they pay their CEOs. Lown Index data on pay equity found that nonprofit hospital CEOs are paid eight times the rate of hospital workers without advanced medical degrees, on average. Creating incentives for CEO pay based not only on financial performance but patient outcomes, community investment, and other social responsibility metrics, would help align incentives for leadership with those of the community.

Committing to providing a living wage for all hospital workers would be an incredible boost for financial security within the community. The median wage for health care support, service, and direct care jobs was $13.48 an hour in 2019. California took a giant step by raising the minimum wage for healthcare workers to $25 an hour. Because hospitals are often one of the largest employers in a region, raising the minimum wage helps to support local economic development, and could even improve community health. 

We’re envisioning a 2024 full of innovation and collaboration in the hospital space, and these socially responsible hospitals give us hope that this vision will become a reality. We hope you will join us next year as we continue to build the movement for socially responsible healthcare.

The post Five ways hospitals can be more socially responsible in 2024 appeared first on Lown Institute.

While coronary stents can be lifesaving for an acute heart attack, decades of research shows that they are not beneficial for patients with stable heart disease. Yet hospitals perform hundreds of thousands of these procedures unnecessarily, exposing patients to needless risk and wasting billions.

Why do doctors continue to do procedures without evidence they benefit patients? At a panel discussion hosted by the Lown Institute, overuse experts David Brown, Thomas Power, Betty Rambur, and Vikas Saini discussed the implications of stent overuse, what causes overuse, and what we need to change. Watch the full video recording of the event below:

How prevalent is stent overuse?

The Lown Institute report found that more than one in five stents that hospitals performed from 2019-2021 for Medicare patients met criteria for overuse. Stents were defined as meeting overuse criteria for patients with a diagnosis of ischemic heart disease at least six months prior to the procedure, excluding patients with a diagnosis of unstable angina or heart attack within the past two weeks, and excluding patients who visited the emergency department over the past two weeks.

The rate of overuse varied widely among hospitals; at some hospitals, more than 40 percent of all stents were overuse, while at others, fewer than 10 percent were overuse.

The panelists found these numbers illuminating, but not shocking. In fact, Dr. Brown found the hospitals on the low end the most surprising, expecting even the low outliers to have much higher overuse rates.

“[These results are] the logical consequence of unbridled overuse of services.”

Betty Rambur, Professor of Nursing at the University of Rhode Island

What’s driving stent overuse?

Our panelists pointed out many reasons why a clinician might perform an unnecessary stent. The narrative of an artery being a “clogged pipe” that just needs to be opened is very convincing both for doctors and patients. In reality, a clogged artery is indicative of systemic heart disease that requires medication and lifestyle changes; simply opening one artery won’t prevent future cardiovascular events, said Brown.

“When a patient is shown a coronary angiogram showing right narrowing of an artery… there is an intuitive desire to make it go away.”

Dr. David L. Brown, Clinical Professor of Medicine, Keck Medicine of USC

Another reason is that guidelines are far behind the evidence, making change a slow process. Medicare’s coverage guidelines allow doctors to be paid for stents that we now know do not benefit patients — as long as Medicare will still pay for them, our health system will deliver them. Specialty guidelines also have not kept up with evidence. For example, the American Heart Association’s latest chest pain guidelines are “full of recommendations for procedural overuse…modeled on the clogged pipe paradigm of coronary disease” said Brown. “They’ve been missing in action, to say the least.”

And of course, financial incentives play a role. Our fee-for-service payment system incentivizes hospitals to do more elective procedures, and gives less to hospitals spending more time with patients or pursuing preventive measures. The $2.4 billion in waste from overused stents could be put to a much better use.

“There are harms to other patients by using healthcare dollars on low-value services, thereby depriving other patients of services that are higher value.”

Dr. Thomas Power, Senior Medical Director of Cardiology and Sleep Programs at Carelon Medical Benefits Management

Despite being the wealthiest country in the world, we have a “resource-constrained system” because not everyone can access the care they need. Imagine what the billions we spend on low-value care each year could do to change that.

The post The prevalence and harm of unnecessary stents appeared first on Lown Institute.

Every seven minutes, a Medicare patient receives an unnecessary coronary stent at a U.S. hospital, a new report finds. The Lown Institute, an independent think tank, examined overuse of percutaneous coronary interventions (coronary stent or balloon angioplasty) at 1,733 general hospital inpatient and outpatient facilities, and found more than 229,000 procedures met criteria for overuse.

While coronary stents can be lifesaving for someone having a heart attack, years of research shows that stents for stable heart disease provide no benefit over optimal medication therapy. Across all hospitals, Lown estimates that more than one-in-five stents were placed unnecessarily in Medicare patients from 2019 to 2021, at a cost of $2.44 billion.

“When physicians continue a practice despite the evidence against it, it becomes more dangerous than useful.” said Dr. Vikas Saini, a cardiologist and president of the Lown Institute. “The overuse of stents is incredibly wasteful and puts hundreds of thousands of patients in harm’s way.”

Possible complications from the procedure include tear or perforation of the coronary artery, infection or bleeding at the catheter site, blood clots that can lead to stroke or heart attack, and kidney damage from the dye or contrast.

Rates of overuse varied widely across hospitals, including institutions in the same state. In South Carolina, for example, 42 percent of stent procedures at MUSC Health Columbia Medical Center Downtown (formerly Providence Health) met criteria for overuse, while at Grand Strand Medical Center the rate was only 6 percent.

Hospitals with highest rates of stent overuse, 2019-2021

Includes general hospitals with above-average volume of total stents, in order of highest proportion of stents meeting overuse criteria.

Hospitals with lowest rates of stent overuse, 2019-2021

Includes general hospitals with above-average volume of total stents, in order of lowest proportion of stents meeting overuse criteria.

“The frequency at which stents are overused shows that many physicians are struggling to keep up with the evidence,” said Dr. Saini. “To be socially responsible, hospitals need to take a more active role in reducing these unnecessary procedures.”

Methodology

The Lown Institute examined overuse of percutaneous coronary interventions (coronary stent or balloon angioplasty) for 1,773 hospitals with the capacity to perform the procedure. Medicare Advantage and fee-for-service claims were used for 2019 and 2020; only fee-for-service claims were included for 2021 as Medicare Advantage claims were not available.

Stents were defined as meeting overuse criteria for patients with a diagnosis of ischemic heart disease at least six months prior to the procedure, excluding patients with a diagnosis of unstable angina or heart attack within the past two weeks, and excluding patients who visited the emergency department over the past two weeks.

Total Medicare spending on low-value stents was calculated using Medicare’s per-procedure cost of $10,615, the most frequent procedure code used for PCI in our analysis. Of this cost, $9,015 is paid by Medicare and $1,600 is paid by beneficiaries for fee-for-service Medicare patients. Our cost estimate assumes that the cost of stents for Medicare Advantage patients is similar to beneficiaries in traditional Medicare.

Only hospitals performing above the national average volume of total stents were considered for the top and bottom lists.

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SEE ALSO

• The best and worst hospital in each state for stent overuse
• Summary of research on stent overuse

About the Lown Institute

The Lown Institute is an independent think tank that conducts bold and uncompromising research and advocates for a just and caring system of health. The Lown Institute Hospitals Index for Social Responsibility is a signature project of the Institute and features measures never used before like racial inclusivity, avoidance of overuse, and pay equity.

Contact

Aaron Toleos, Lown Institute, (978) 821-4620, atoleos@lowninstitute.org

The post PRESS RELEASE: Unnecessary coronary stents cost Medicare as much as $800 million per year appeared first on Lown Institute.

A recent report from the majority staff of the Senate Health, Education, Labor, and Pensions (HELP) Committee, chaired by Senator Bernie Sanders, called out some large nonprofit hospital systems for underspending on financial assistance and engaging in predatory billing activities. What can policymakers do about this issue to protect patients from medical debt and ensure hospitals are giving back their fair share to communities? 

Here are some proposals that could move the needle. 

1. CLEARLY DEFINE COMMUNITY BENEFIT: Currently, hospitals get a lot of leeway in determining what counts as a “community benefit.” Any program that purports to improve community health can count, even if it has nothing to do with what community members have said matters most to their health. Congress should create a clearer definition of community benefit that ties spending directly to the priority health needs identified in the community health needs assessment that hospitals are required to conduct, as states like Massachusetts do already.
2. BETTER REPORTING: The IRS requires hospitals to report their spending on several community benefit categories on their Form 990 Schedule H, but current reporting requirements have holes. For example, hospitals are allowed to report their spending aggregated at the system level, which reduces transparency by masking differences in spending by individual hospitals. Congress could direct the IRS to make facility-level reporting of Schedule H a requirement, as several states already do. They could also enable communities to more easily see if hospitals are spending their fair share by requiring hospitals to report the value of their local property and sales tax breaks.
3. FINANCIAL ASSISTANCE STANDARDS: Currently, hospitals in most states do not have a set standard on who they must make eligible for financial assistance or how much they must spend. Congress could do what California and other states have done, and set specific standards for nonprofit hospitals to ensure that patients under a certain poverty level (depending on the state or local economic conditions) receive care that’s free or discounted. Congress could also create a standard financial assistance application all hospitals must make available and disallow barriers to assistance like asset tests for patients that qualify.
4. CB SPENDING MINIMUMS: Nonprofit hospitals are not required to spend a certain amount on community benefits to maintain their tax-exempt status, giving them little incentive to increase their spending. Congress could encourage hospitals to spend more by providing tax benefits on a sliding scale based on how fully hospitals comply with the community benefit standard compared to their peers, so that hospitals meeting the bare minimum would get a smaller tax break. Or they could follow Oregon’s example and set a community benefit spending floor for all hospitals, based on hospitals’ financial positions and local need, to ensure hospitals give back at least a certain amount.
5. PREDATORY BILLING RESTRICTIONS: Nonprofit hospitals are allowed to take “extraordinary collection actions”–send patients’ medical debt to collections, sue patients for medical debt, garnish their wages, or refuse patients with debt nonemergency care–if they have “made reasonable efforts” to determine whether someone is eligible for financial assistance before doing so. However, there are many cases in which hospitals take these actions against low-income patients who should have received assistance. Congress should disallow these actions entirely for nonprofit hospitals or issue fines to hospitals who are found to have taken these actions against patients who should have qualified for financial assistance. At the very least, they could require hospitals to report on their IRS 990 the number of patients they’ve taken extraordinary collection actions against in the past year.
6. CEO PAY LIMITATIONS: Some nonprofit hospital CEOs make tens of millions each year, despite spending little on community benefits. While capping CEO pay outright—as some have proposed—would be most simple, the political feasibility is low. However, policymakers could place additional requirements on hospitals that pay their CEOs an “excessive” amount, such as halting all extraordinary debt collection actions or requiring a living wage for all employees.

This is just a sample of the many ideas that health policy experts and community health advocates have proposed to make the community benefit standard more meaningful, reduce medical debt, and attend to community health needs. For policymakers worried about small hospitals being able to comply, critical access hospitals could be excluded, or policies could be targeted specifically at large nonprofit hospitals or systems.

Whichever route policymakers decide to take—through transparency, regulation, or all of the above—urgent action on this issue is needed for the physical and financial health of our communities.

The post Six ways Congress could improve the hospital community benefit standard appeared first on Lown Institute.

How have hospital equity officials addressed racism within their institutions and in healthcare, and what challenges have they faced? In Health Affairs, researchers from Brigham and Women’s Hospital, Harvard University, the American Hospitals Association, and the Commonwealth Fund surveyed 340 hospital equity officers from across the country. A smaller subset of 18 officers participated in longer qualitative interviews.

Advancements in equity

The survey results and interviews show where strides have already been taken towards health equity. Here are a few of the key takeaways on the positives:

• Buy-in for health equity work among hospital leadership appears to be high. Eighty-four percent of equity officers reporting that their CEO was very supportive of their efforts, and 64% said that the hospital board was very supportive.
• Data collection on demographic characteristics is widespread. A large majority (88-94%) reported routinely collecting data on patients’ race, ethnicity, language, and social determinants of health.
• Common activities to address racism include collecting information about instances of racism within the hospital (54% of officers reported doing this) and forging community partnerships to improve equity through events like listening sessions (66%).

“I think any executive needs the health equity lens. We should all have it.”

Equity officer interview participant, Health Affairs

Room for improvement

Researchers also identified obstacles to change and room for improvement:

• While support from hospital leadership for equity efforts was high, fewer respondents (52%) said they that clinical leaders were very supportive; some cited pushback from clinicians who saw health equity efforts as an accusation of bias.
• Not all institutions have committed to specific equity goals. Only 68% of survey respondents said that their hospital had specific goals or strategies to reduce inequities in the clinical care by race/ethnicity, and fewer than 50% had strategies for reducing disparities based on sex, gender identity, or sexual orientation.
• The biggest obstacles to change that officers cited were lack of diverse staff (25% reported as a “major obstacle”) and lack of a standardized way to record data on social determinants of health (26%). Some officers noted that the political climate kept them from announcing their equity initiatives publicly for fear of backlash.
• Relatively few respondents (22%) reported that their hospital was reviewing clinical algorithms for potential bias.
• Although almost all respondents said their institution collected data on race and ethnicity, only half said they used this data to stratify performance metrics (more likely in teaching and urban hospitals or systems). Why such a low rate? Officers cited doubt in the validity of this data and lack of systematic collection practices.

“Fuzzy data in, fuzzy results, right? So, we have a lot of fuzzy data.”

Equity officer interview participant, Health Affairs

Where to go next?

Equity officers identified the need for certain tools and guidelines that could help advance equity at their hospital:

• One of the largest barriers to using data has been a lack of standardized practices for collecting data, especially for social determinants of health. Issues of privacy and patient trust are important to consider when asking patients about health-related social needs.
• Equity officers noted the need for more tools and curricula for training hospital staff on DEI issues.

“What are the right clinical settings to collect [social determinants of health] data? How do we collect it in a confidential manner? When should it be collected? How often should it be collected? What do we do with the data once we have it?”

Equity officer interview participant, Health Affairs

Creating DEI positions is not a cure-all for healthcare inequities; it’s just the start. These findings provide a peek into how hospital equity leaders are making change, and how researchers and policymakers can help their work forward.

The post “We should all have an equity lens”: Insights from hospital equity officers appeared first on Lown Institute.

To learn more about what experts in the field are saying about this issue, check out this recent STAT News article quoting Lown Institute president Dr. Vikas Saini.

Private equity takeovers

The past few years have seen rising private equity investment in healthcare, with 9% of all private and 30% of all proprietary for-profit hospitals owned by private equity firms. What does this mean for health system performance?. 

“The interest of private equity in cardiology is not humanitarian. They see dollar signs and they’re going for them.”

Dr. Vikas Saini, president of the Lown Institute, in StatNews

A systematic review of 55 publications exploring the effects of private equity ownership on healthcare system performance gives us the bottom line up front: private equity ownership in healthcare means higher costs for both patients and payers and a range of mixed to harmful effects on quality of care. To better understand this phenomenon, let’s take a closer look at private equity’s newest fixation: cardiology.

Why cardiology?

Fields like dermatology, ophthalmology, gastroenterology, and others have attracted private equity firms’ attention because of the ability to conduct elective procedures in the outpatient setting. Medicare’s 2020 rule allowing for reimbursement for cardiac procedures in ambulatory surgery centers – along with the prevalence and severity of cardiac disease in the US –  has made cardiology an attractive target for private equity firms. According to StatNews, at least 10 private equity firms are “racing” to buy up cardiology practices. They are tracking hot spots for cardiology acquisitions that have popped up in Florida, New Jersey, New Mexico, and other states.

The shift to outpatient and cardiac care overuse

The shift of cardiac procedures to outpatient settings combined with private equity investment may increase the risk of overuse, or unnecessary procedures. 

CMS boosted reimbursement rates for stents performed in outpatient settings in 2008, based on a desire to increase procedural efficiency and cut costs. But they may have fueled the cardiac overuse crisis by creating a financial incentive for physicians to perform more and more procedures, regardless of whether they would benefit their patients. For example, ProPublica and the New York Times reported on doctors who conducted dozens of unnecessary vascular procedures, leading some patients to have their legs amputated. 

Unnecessary coronary stenting may be next. Coronary stenting – also referred to as percutaneous coronary intervention (PCI) – involves the insertion of a small, mesh tube inside the coronary arteries to widen blood vessels that are narrowed or blocked by plaque. 

While coronary stents can save lives when someone is having a heart attack, several studies have indicated that their utility is limited beyond that. Coronary stents do not benefit patients with stable heart disease, nor are they an effective tool for preventing cardiac events or reducing symptoms such as angina when compared to a placebo. Despite this evidence, top-performing hospitals continue to embrace and profit from this procedure, charging insurers up to $25,521 per PCI.

However, coronary stents are only a small piece of the financial prize that is cardiac overuse. A 2019 study revealed that non-invasive cardiologists produced $2.31 million and invasive cardiologists $3.48 million annually for the hospitals in which they were affiliated.

The financial promise of private equity ownership of cardiac care raises alarm bells for cardiologists such as Lown Institute President Dr. Saini. Private equity firms insist they will act in accordance with provider guidelines and stay out of providers’ operations, but who’s watching them? With the intersection of private equity and overuse looming large, we need the answer to this question.

The post Private equity in cardiology raises overuse concerns  appeared first on Lown Institute.

Guest panelists were: 

• Dr. Uché Blackstock, ​​founder of Advancing Health Equity, which partners with healthcare organizations. Her forthcoming book, Legacy: A Black Physician Reckons with Racism in Medicine, will be released in January 2024.
• Dr. Selwyn Rogers, acclaimed surgeon and founding director of the University of Chicago Trauma Center. He was recently named an associate editor for the New England Journal of Medicine and serves as a member of the Lown Institute Board.
• Dr. Elena Mendez-Escobar, Co-Director at the Health Equity Accelerator at Boston Medical Center, responsible for strategy.

Why hospital segregation happens

The Lown Institute’s racial inclusivity metric shows how well hospitals serve patients from communities of color in their surrounding area. We consistently find that some of the most and least racially inclusive hospitals are in the same metro areas, demonstrating patterns of segregation in American cities. (See the cities with the most segregated hospital markets on the Lown Hospitals Index website.)

More than fifty years after segregation was outlawed, we still see segregation in healthcare in similar ways that we see in education and housing. In racially diverse urban areas, some hospitals are disproportionately serving communities of color while others disproportionately serve patients from whiter and wealthier areas.  

Why does this happen? Redlining and other forms of residential segregation; inequities in reimbursement rates for patients based on insurance status, which correlates with race; differences in hospital culture and staff diversity; and many other factors play a role. 

“What we’re really looking at are the long-term effects of structural racism and classism.”

Dr. Vikas Saini

However, just because hospital segregation is long-standing doesn’t mean we should tolerate or normalize it, panelists said. “People expect these differences to exist, and sometimes that can paralyze us. It shouldn’t be this way,” said Dr. Mendez-Escobar. 

Policy solutions for more inclusive hospitals  

How do we begin to solve such a complex and entrenched problem? One of the big structural elements that perpetuate segregation is the way we pay hospitals–giving them more to care for patients with private insurance, and more to perform elective procedures rather than preventive care. 

“We pay [hospitals] for doing stuff…there’s not a lot of pay in not doing stuff, and there’s even less pay in preventative things that for the most part fall into the public health realm.”

Dr. Selwyn Rogers

We’ve created a “two-tiered system,” said Dr. Mendez-Escobar. It’s not only a segregated system but it’s also unequal, as the hospitals serving more patients of color tend to have the least amount of funding, she said.

In many ways, segregated hospital markets reflect a “segregated insurance market,” said Dr. Saini. “It seems pretty obvious that if all patients meant the same revenue opportunity for everybody all the time…we’d go a huge way toward removing some of the structural impediments,” said Saini.  

This can have a large impact on who can access care or feels welcome at certain hospitals. For example, Dr. Blackstock recalled working at an academic medical center where EMTs did not bring certain patients to the hospital because they were worried about getting in trouble for doing so.

But that’s just one piece of the puzzle, panelists said. Even a single-payer system wouldn’t solve the issues of structural racism that impact health access. Dr. Blackstock noted that communities that have high levels of interaction with police have greater mistrust in the health system, and therefore may not seek treatment for unmet health needs even if they have insurance. “We really have to understand the myriad of ways that systemic racism plays out,” she said. 

What hospitals can do

Larger policy changes are undoubtedly needed to close racial health gaps, but there are still many things hospitals can do on an individual level to improve inclusivity and reduce disparities. 

“Hospitals can’t change the past, we can’t change the present, but we can influence the future. We have to be intentional.”

Dr. Selwyn Rogers

One way to tackle upstream health outcomes is through equitable hiring decisions and investing more into communities of color. Income is one of the key social drivers of health and hospitals are often some of the largest employers in their community; the decisions hospitals make about who to hire, who they promote, and how they procure resources can have a large impact in financial security of their communities. BMC offers financial coaching to patients as one way to improve financial security as well, said Mendez-Escobar. “If you’re the economic engine, buy local,” Rogers added. 

To make a difference in health disparities, hospitals have to see equity as a quality issue, panelists said. That means tracking outcomes metrics across racial, ethnic, and socioeconomic groups, identifying disparities, and evaluating the impact of interventions. For example, at BMC there was a large racial disparity in how long it took patients to undergo a cesarean section after they had decided to have the surgery. A longer time before surgery creates more opportunity for complications. By standardizing a goal of 60 minutes or less for all patients, outcomes improved for patients of all races, but especially helped Black patients. 

“This is not rocket science. This is really about centering the communities that your hospital has a mission to serve.”

Dr. Uché Blackstock

Additionally, involving community members directly in hospital decision-making is key. At UChicago, they have a community action council, of about 20 representatives from the community, who provide guidance and advice to hospital leaders. Dr. Blackstock agreed that hospitals can “look more at community governance models where community members, employees, even patients are involved in helping develop health equity metrics to ensure transparency.”  

For much more on this topic, watch the full video of the event and see the racial inclusivity results from the Lown Hospitals Index.

The post WATCH: How hospitals can improve racial inclusivity appeared first on Lown Institute.

Many of the most and least inclusive hospitals are in the same cities, analysis finds

BOSTON, MA – Most hospitals say advancing health equity in their communities is a priority, and a new report examines just how well they’re doing. The Lown Institute, an independent healthcare think tank, ranked over 3,000 U.S. hospitals on how well they served patients of color, using Medicare data from 2021.

Disparities in healthcare outcomes and access are well-documented in communities of color, including higher rates of chronic conditions, lower life expectancy, and lower rates of private insurance. Lown examined the racial and ethnic demographics of patients to gauge how effectively hospitals target care to those populations. Racially inclusive hospitals served more patients of color than expected based on the demographics of their service area.

“It’s refreshing to see that some hospitals make caring for those most in need their top priority,” said Vikas Saini, MD, president of the Lown Institute. “Inclusive hospitals show that it’s possible to serve everyone, even when it may be against their financial interest.”

The following hospitals are the most racially inclusive in America:

1. Boston Medical Center (Boston, MA)
2. John H. Stroger Jr. Hospital (Chicago, IL)
3. UChicago Medicine (Chicago, IL)
4. Penn Presbyterian Medical Center (Philadelphia, PA)
5. Metro Nashville General Hospital (Nashville, TN)
6. South Coast Global Medical Center (Santa Ana, CA)
7. St. Charles Madras (Madras, OR)
8. Grady Memorial Hospital (Atlanta, GA)
9. Methodist Hospitals (Gary, IN)
10. Emory University Hospital Midtown (Atlanta, GA)

Segregated healthcare markets

The Institute also found that many of the most and least racially inclusive hospitals are located in the same U.S. cities, reflecting segregated healthcare markets. Of the 11 metro areas identified by the Lown Institute with significant market segregation, New Orleans stands out at the top of the list, with seven of its 14 hospitals (50%) ranking among the most or least inclusive.

The U.S. cities with the most segregated hospital markets are:

1. New Orleans, LA
2. St. Louis, MO
3. Detroit, MI
4. Milwaukee, WI
5. Philadelphia, PA
6. Kansas City, MO
7. Chicago, IL
8. Denver, CO
9. Phoenix, AZ
10. Dallas/Fort Worth, TX
11. Atlanta, GA

The most segregated hospital markets were determined by examining the proportion of hospitals within a metropolitan statistical area receiving either 1 star (lowest score) or 5 stars (highest score) on Lown’s racial inclusivity ranking. All cities included on the list had more than 20% of hospitals at those extremes.

“Hospitals will say their doors are open to everyone and that they don’t turn anyone away, but that can be misleading,” said Saini. “If hospitals really want to undo structural racism’s hold on their communities, they can’t be bystanders. They need to act more systematically and with more intention.”

For additional ranking information, including a full explanation of methods, see the online report.

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SEE ALSO:
The 50 most racially inclusive hospitals in America
U.S. News Honor Roll hospital racial inclusivity rankings
Each state’s most racially inclusive hospital

About the Lown Institute

Founded in 1973 by Nobel Peace Prize winner Bernard Lown, MD, developer of the defibrillator and cardioverter, the Lown Institute believes that a radically better system of health is possible and generates bold ideas towards that goal. The Lown Institute Hospitals Index for Social Responsibility is a signature project of the Institute and features measures never used before like racial inclusivity, avoidance of overuse, and pay equity.

MEDIA CONTACT: Aaron Toleos, Lown Institute, (978) 821-4620, atoleos@lowninstitute.org

The post PRESS RELEASE: Think tank identifies America’s most inclusive hospitals appeared first on Lown Institute.

Fee-for-service vs value-based care

In most states, the dominant payment model for healthcare is fee-for-service, in which providers get paid for each service they do. Hospitals and doctors therefore have an incentive to do more tests and procedures, even when they don’t make patients healthier. At the same time, there is little incentive to take on health-related social needs and preventive care that can keep patients out of the hospital in the first place.

The goal of the AHEAD model is to turn these incentives on their head (sorry!). Hospitals in participating states will receive a “global budget” — essentially an annual salary — that takes into account their previous Medicare and Medicaid payments, the populations they serve, and other factors. So when hospitals avoid unnecessary care and reduce preventable hospitalizations by addressing social needs, they get to keep those savings.

AHEAD builds on the success of previous global budget models. In Maryland, they have had global budgeting for hospital inpatient care since 2014, which has led to significant Medicare cost savings and reductions in avoidable readmissions. In Vermont, most hospitals participate in a voluntary accountable care organization model to reduce overuse and better coordinate care. And many rural hospitals in Pennsylvania received fixed global budgets through a CMS pilot program, which gave them financial stability during COVID-19.

The AHEAD model takes these existing models much further, which could result in transformative change for participating states. For one, AHEAD is a ten-year program, so states and hospitals will have the time to invest in primary care and social needs and actually see savings during the program. AHEAD is also comprehensive, including Medicare, Medicaid, and private payers (states are responsible for incentivizing or requiring participation from private insurers); including a voluntary fixed payment model for primary care providers as well as hospitals; and including outpatient as well as inpatient payments in the global budgets. Lastly, AHEAD holds providers accountable for achieving not only quality goals but equity goals as well. Participating states must develop a “health equity plan” for improving population health and reducing disparities.

Challenges ahead

The AHEAD program is promising, but this ambitious plan is going to face many challenges throughout planning and implementation. In a recent piece in Health Affairs, Troyen Brennan, adjunct professor of public health at the Harvard T.H. Chan School of Public Health, identifies potential roadblocks and unanswered questions for CMS.

For example, AHEAD goes further than Maryland’s global budget model by including outpatient care as well as inpatient care. Will hospitals join in the model without this “lifeline of fee-for-service support”? In Maryland’s model, Medicare pays hospitals much higher rates to make up for lower rates from private insurers. Is CMS prepared to offer these much higher rates to hospitals in more states?

Brennan also questions whether hospitals that are financially successful in the current fee-for-service system will take a gamble on global budgets when they might lose money. He writes:

“As a hospital executive, your key strategy, perhaps your only strategy, has been to increase in size, gain leverage with insurers, bargain for better fee-for-service rates, and do more procedures.  Working under a prospective budget blocks that strategy.  So one might ask about Pennsylvania, would centers like UPMC in the west, and Jefferson or University of Pennsylvania in the East, be ready to abandon the fee-for-service revenue generation program for one based solely on value-based care that improves population management. I wish that were true, but it seems doubtful.”

Ever since Maryland launched their global budgeting model, health policy experts have been hoping that other states will follow their lead. The AHEAD program presents an opportunity for more states to dive into the deep end of value-based care, with CMS holding their hand for support. Let’s hope states will take the plunge.

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