Health Equity and Measures Hospital Rankings—Reply

Abstract

To the Editor In a recent Viewpoint, 1 authors from US News & World Report described several health equity measures to be used to evaluate hospitals' performance on 3 dimensions: access, outcome, and social determinants of health. While we applaud the effort to promote health equity and ensure hospital accountability, in this Letter, we highlight some potential limitations of the effectiveness of these measures for evaluating hospitals' health equity performance.The proposed access measure captured how closely the racial composition of Medicare patients undergoing typically elective procedures in a hospital matched Medicare beneficiaries residing in the surrounding community. However, some hospitals that provide specialized care (eg, organ transplants) attract Medicare patients from a broader geographic base. In addition, patients from racial and ethnic minoritized groups may bypass a closer, higher-quality hospital to go to a more distant lower-quality hospital not because of hospital acceptance metrics but because of insurance networks-and hospitals are only one part of the decisions regarding networks. 2 To investigate outcomes disparities, hospital-level differences in the risk of 30-day unplanned readmission were examined between Black and White patients following common surgical procedures. Whether hospital readmission rate is a valid measure of quality is under debate because a given patient's probability of readmission appears heavily influenced by social determinants of health, which hospitals do not directly control. 3 Hospitals may be incentivized to take actions that reduce the racial and ethnic differences in readmission risk without improving health equity, for example, by selectively admitting healthier Black patients and avoiding admissions of individuals with unstable housing or limited social support.In addition, the proposed measure for social determinants of health was the alignment between the proportion of a hospital's cost spent on uninsured charity care and the proportion of uninsured individuals in its communities. However, hospitals provide charity care to both uninsured and underinsured patients, 4 so this measure might reduce incentives for hospitals to assist underinsured patients. Also, nonprofit and for-profit hospitals receive different taxpayer subsidies and thus have different obligations for charity care provision. 4 Organizations adjust behaviors in response to performance measures. We are concerned that the proposed hospital health equity measures outlined in the Viewpoint 1 might induce hospitals to act in ways that do not necessarily improve health equity. More understanding and refinement of these measures are needed to rigorously evaluate hospital performance and motivate hospitals to effectively enhance health equity.

Measuring Local-Area Racial Segregation for Medicare Hospital Admissions

“…In recent years, there have been 2 main approaches to measure inclusivity conditional on the degree of racial segregation . One approach uses Dartmouth hospital service areas (HSAs, of which there are >3000 in the US) as hospital markets rather than driving time, but these service areas vary dramatically in size (for example, Los Angeles, California, is a single HSA) . The other approach defines a hospital’s market based on its current patient composition (which may, in turn, reflect racial sorting), rather than our predetermined 30-minute drive time .…”

Policy Strategies to Advance Cardiovascular Health in the United States—Building on a Century of Progress

“…However, a growing body of evidence suggests that the US health system largely delivers similar—if not better—care to patients with acute illnesses such as MI compared with other countries. 13 Instead, policymakers have failed to confront factors that more likely explain poor health outcomes in the United States—pervasive disparities in access to primary and preventive care services, widening inequities in income, wealth, and education, and unequal geography of opportunity, 14 which collectively contributes to the 20-year life expectancy difference across US counties. CMS has started to encourage health systems to identify health-related social needs, but broader and cross-sectoral state and federal policy actions will be required to tackle the underlying social drivers of poor health (eg, poverty), which disproportionately impacts minoritized populations in the United States.…”

Hospital Equity Rating Metrics—Promise, Pitfalls, and Perils

“…The USNWR care access and preventive care metrics pull demographic data from Medicare administrative files, which may introduce missing data bias. Race and ethnicity imputation methods have been used with some success, but the acceptable amount of missing data, valid and acceptable imputation methods, and predictive accuracy of methods by race and ethnicity need to be specified …”

“…Multiple hospital regulatory and accrediting organizations that assess and rate quality of care—The Joint Commission (TJC), US Centers for Medicare & Medicaid Services (CMS), US News & World Report (USNWR), The Leapfrog Group, and Lown Institute—want to hold hospitals accountable for health equity in the care they provide. They seek to determine how well hospitals achieve equitable access to care and outcomes for marginalized and minoritized communities and address inequities such as social drivers of health.…”