INTRODUCTION: THE BEST HOSPITALS FOR AMERICA.

AuthorGarcia, Cole

Since early this spring, a flood of patients infected with the novel coronavirus has stressed many of the nation's hospitals to their limits, revealing like never before what's good, bad, and ugly about our health care system.

On the positive side, we've seen extraordinary selflessness and heroism from the people who work in hospitals. Doctors have come out of retirement to lend a hand. Nurses have separated themselves from their families to avoid infecting them. Respiratory therapists, technicians, janitors, patient transporters, and even administrators are literally putting their lives on the line. As of April 7, the Centers for Disease Control and Prevention estimated that COVID-19 had infected 9,000 health care workers and killed at least 27, though the true numbers are undoubtedly far higher. Even some hospital CEOs have done their part by forgoing a few months of pay in order to avoid having to furlough workers.

On the not-so-heroic side, this crisis has also brought news of misbehavior. One major teaching hospital, the University of Pittsburgh Medical Center, continued scheduling lucrative elective surgeries long after the state's governor ordered hospitals to stop such surgeries so they could prepare for the surge of COVID-19 patients. (See Phillip Longman and Udit Thakur, "An Epidemic of Greed," page 26.) One uninsured woman in Boston who had symptoms of COVID-19 got a $34,000 bill for her emergency room treatment. Some hospitals have maintained aggressive bill collection practices, dunning working-class patients whose incomes have plunged in the pandemic-induced recession. Still others have threatened to fire workers who speak publicly about the lack of personal protective equipment (PPE) and refused COVID-19 tests for people with symptoms while offering them to the rich and famous.

More than anything, the crisis is driving home the cruel inequities between neighborhoods and the hospitals that serve them. Numerous reports show that black and Hispanic Americans are being hospitalized and dying of COVID-19 at much higher rates than other groups. That's likely a consequence of several factors, like the fact that they disproportionately work in higher-risk professions like food service, and live in more vulnerable circumstances, such as multigenerational homes.

They're also being cared for, often, in hospitals with fewer resources. Places like Elmhurst Hospital Center, a large safety net hospital serving a mostly working-class and immigrant population in Queens, New York, struggled to find PPE for its frontline workers as an apocalyptic number of patients descended at the height of the infection. Across the East River in Manhattan, Mt. Sinai, the prestigious teaching hospital on Central Park, was able to procure N95 masks from a hospital in China with private jets owned by Warren Buffett.

These inequities are built into the way hospitals in America are allowed to do business. A majority of them are technically nonprofits, but the largest, most prestigious ones often earn returns that would make a Fortune 500 CEO envious. Mt. Sinai's operating revenue grew nearly 7 percent in 2019, and it had more than $700 million in reserves. It achieved this bonanza in part by marketing high-margin elective procedures, like cardiac stents, to wealthier patients with good insurance. Prestigious hospitals also stay profitable by not serving their fair share of lower-income patients and people of color--people who may lack insurance altogether and often have multiple chronic conditions, like diabetes, that are not very profitable to manage.

That sort of behavior forces safety net hospitals like Elmhurst to pick up the slack, which typically leaves them struggling financially to find the revenue, personnel, and equipment to do their jobs. An audit a decade ago found that Elmhurst patients had to wait an average of 148 days for routine mammograms, the longest wait in the city.

The current structure of our hospital system doesn't just reflect the inequities of the American economy, it also helps drive them. Over the last decade, health care costs per capita have risen twice as fast as wages. In fact, a major reason why wages have barely kept up with inflation for decades for most middle- and lower-income Americans is that more and more of their income is being funneled, via payroll deductions, into the health care system. The system's costs keep rising in part because hospitals have been merging, creating local monopolies with the power to demand higher prices, and indulging in "overtreatment"--that is, performing tests and procedures, like knee arthroscopies, that studies have shown are either completely ineffective or no better than less invasive and less expensive treatments. Overtreatment also puts patients at needless risk of everything from medical errors to hospital-acquired infections to drug mishaps, which together kill as many as a quarter of a million hospital patients each year.

The pandemic has been a great equalizer in one sense: Regardless of which class of patients they serve, hospitals are getting financially creamed because of the high costs of treating COVID-19 patients and a nationwide drop in profitable surgeries. The federal government has responded with more than $100 billion in aid to hospitals. But that will almost certainly wind up just being a down payment. Hundreds of billions more tax dollars will be needed.

Rather than hand that money over with no strings attached, federal lawmakers should treat the bailout as a chance to fundamentally rethink the nation's entire health system and the role hospitals should play in it. After all, a third of the more than $3.6 trillion we spend annually on health care flows through America's hospitals--much of it tax dollars, from Medicare payments to research grants to the enormous monetary benefits that come with tax-exempt status, on top of the bailout funds. Taxpayers have a right to demand some accountability for all that money.

If we want to start holding hospitals more accountable for improving their performance, however, we first need a reliable set of metrics to hold them accountable to. Unfortunately, those metrics don't exist--not in government or the private sector.

The most well-known and influential rating of hospital performance, U.S. News & World Report's "America's Best Hospitals" list, is certainly not up to the task. More than one-fourth of a hospital's score on the U.S. News rankings is based on a survey of medical specialists. As such, it is largely reflective of high national brand-name recognition, which is fueled in part by the rankings themselves. Its other metrics focus almost entirely on the outcomes of the patients a hospital admits, paying no attention to a propensity to overtreat or the degree to which it is treating the health needs of the broader population of its community. And the magazine's rankings have real power. Hospital administrators spend time and money in order to climb up the list, because doing so gives them bragging rights they can use to bring in more well-insured patients. Other rating systems, like IBM Watson Health's "Top 100 Hospitals," aren't much better. If you want to know where to get your hip replacement, these guides do a fine job. If you want to know which hospitals are using their resources wisely to provide quality care to everyone in their communities, they tell you literally nothing.

That's why the Washington Monthly teamed up with the Lown Institute, a nonpartisan health care think tank, to create our "Best Hospitals for America" ranking. We used data drawn from the Lown Institute Hospitals Index not only to measure how well hospitals care for their patients but also to gauge the contributions hospitals make to the country and their communities. Our rankings use three main criteria. First, quality of care: a hospital's patient mortality, safety, and satisfaction record. Second, civic leadership: the degree to which a hospital treats patients with the same income and other demographics as its surrounding community; how much it contributes in community benefit, from providing charity care to building and operating free clinics; and how much it pays its senior executive compared to its frontline workers. Third, value of care: how much a hospital overuses low-value tests and procedures.

We then created an "honor roll" of 20 hospitals, each of which achieved the rare feat of scoring notably better than average--in the top 45 percent--in each category (many scored much higher, see page 14). We excluded hospitals from the honor roll that were missing data for one or more of the components. For like-to-like comparisons, we also ranked the 50 best major teaching hospitals out of 224 nationally (page 16) and the 100 best safety net hospitals out of more than 650 nationally (page 18).

(For a more detailed methodology, see page 31. For the full ranking of more than 3,200 hospitals, see the Lown Institute Hospitals Index at www.LownHospitalsIndex.org. For the backstory on how these rankings came about, see the Editor's Note on page 4 and brief explanatory essay from the Lown Institute on page 22.)

Given our different approach to measuring success, we expected that our lists of top hospitals would look different from U.S. News and other rankings. We had no idea just how different.

Like the Monthly, U.S. News publishes an "honor roll" of its top hospitals. Amazingly, not one of the 20 institutions on the U.S. News honor roll appears on ours. U.S. News's list is made up entirely of brand-name teaching hospitals, including Mt. Sinai, which it ranks 14th. None of its winners are safety net hospitals. Our honor roll, by contrast, contains a mix of well-regarded (if not necessarily world-famous) teaching hospitals, such as University of Colorado Hospital in suburban Denver; safety net hospitals, like Oroville Hospital in California's Central Valley; and an assortment of community hospitals of varying...

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