Health Affairs ForefrontHealth Equity
New Hospital Rankings Assess Hospitals’ Contributions To Community Health With A Focus On Equity
US hospitals have some of the most highly trained practitioners, advanced medical treatments, and highest per capita health care spending in the world. Yet, people living in the US have worse health outcomes compared to most high-income nations. From 2015 to 2017, even before the COVID-19 pandemic, life expectancy in the US declined for the first time in nearly a century. In addition, substantial health disparities persist along racial, ethnic, and socioeconomic lines. The COVID-19 pandemic has accentuated and reinforced these disparities: In 2020, Black Americans’ life expectancy has been projected to decrease by three years and Hispanic Americans’ life expectancy by two years, while the country’s overall life expectancy decreased by one year compared to 2017.
This paradox is rooted in the social drivers of health. Economic, environmental, educational, and social factors impact rates of illness in the population. Solutions include investments in primary care and public health, efforts to address the social causes of disease, and a commitment to health equity, defined by the Robert Wood Johnson Foundation as when “everyone has a fair and just opportunity to be as healthy as possible.” The role of hospitals in contributing to these solutions is evolving. In 2017, the National Academies of Medicine found that the most effective hospital contributions to the care of socioeconomically disadvantaged populations are “community informed and patient-centered systems practices” that include (1) commitment to health equity, (2) data and measurement, (3) comprehensive needs assessment, (4) collaborative partnerships, (5) care continuity, and (6) engaging patients in their care. And the call for hospital rankings to incorporate community health and equity into their assessments is growing.
Hospitals increasingly recognize the importance of promoting community health and equity for the patients they serve, their employees, and their communities. Some hospitals have made unprecedented investments in safe and affordable housing, in programs employing community health workers, and in efforts to pay all employees a livable wage.
However, hospital evaluation systems and recognition programs have not kept up with these changes, leaving hospitals’ efforts and innovations in the areas of community health and equity unrecognized. Only a few specialized ranking systems, such as the Lown Institute Hospitals Index and Foster McGaw Prize, incorporate community health into their evaluations. Currently, none of the major hospital performance methodologies comprehensively evaluate hospitals’ impact on community health or equity.
The lack of metrics slows efforts to reward hospitals for work on community health and equity. For example, many health plans in Medicare Advantage and Medicaid are beginning to understand, value, and cover social determinants of health; these plans could develop value-based care payments that support hospitals and health systems that are doing this work.
Creating A Measure Of Hospital Contributions To Community Health And Equity
In the summer of 2020, IBM Watson Health and faculty from the Center for Health Equity and the Bloomberg American Health Initiative at Johns Hopkins University collaborated to create a measure of hospital contributions to community health with a focus on equity. From the beginning, the goal was to incorporate this new measure into the IBM Watson Health 100 Top Hospitals methodology and ranking process in 2021.
This effort proceeded in three stages. First, the Johns Hopkins partners posted a draft measure, aiming to identify ways in which hospitals were working to improve community health that were rooted in evidence and based in existing and emerging practices. This draft was shared via press release, email, webinars, and media events. The Johns Hopkins partners also solicited feedback and exchanged ideas about the measure through meetings with hospital associations, hospital and health system leaders, community organizations, health advocates, and subject matter experts.
Next, more than 100 people and organizations responded with more than 600 discrete comments. These comments ranged from questioning why hospitals should prioritize community health versus focusing only on providing excellent care to their own patients to suggesting additional ways to measure community health impact beyond the methods included in the proposal.
Then, the Johns Hopkins partners substantially revised the proposal based on the comments, releasing a 31-page document responding to each of the comments received. On January 19, 2021, the Johns Hopkins partners sent a final proposal to IBM Watson Health.
The proposed measure had four components. The first component is a quantitative measure of change over 10 years in a key measure of health outcome, such as the number of premature life years lost or the number of avoidable hospitalizations at the county level. Hospitals would receive credit for Component 1 if their home county ranks in the top tertile of the metric. However, data were not available for inclusion of this component in the measure this year.
The remaining three components of the proposed measure assess hospital contributions to community health with a focus on equity with respect to three roles that hospitals serve in their communities: provider, community partner, and anchor institution. (A full list of the best practice standards within each component is available online.) Hospitals would receive credit in each domain for meeting a certain number of best-practice standards. These components were included in the Watson Health 100 Top Hospitals® ranking in 2021.
Component 2 assesses hospital contributions to community health as a health care provider. Best-practice standards in this category include providing buprenorphine treatment for opioid use disorder in the emergency department, running a hospital-based violence prevention program, and offering an infant safe sleep education program. Many of these practices bear directly on efforts to close unacceptable disparities in care and outcomes. Hospitals can get credit for this component by following at least six of the 12 best practices.
Component 3 identifies ways that hospitals contribute to community health as a community partner. For example, hospitals can develop a community needs assessment in collaboration with the department of health, community-based organizations, and community residents. Also, hospitals can provide meaningful support for healthy, affordable housing, and support for a community-based diabetes prevention program. Many of these practices relate to major inequities that undermine health. Hospitals get credit for Component 3 if they meet at least four of the eight best-practice standards.
Component 4 focuses on the ways that hospitals promote community health through their practices as so-called anchor institutions. Examples of best-practice standards in this component are for hospitals to pay all employees a minimum hourly rate based on the local living wage and adopting a “do no harm” medical charges collection policy. Additionally, hospitals can have a minority-owned business purchasing and procurement goal and make progress toward this goal. Hospitals get full credit for Component 4 by meeting at least four of the eight best practices.
IBM Watson Health is incorporating Components 2, 3, and 4 of this measure into their hospital rankings .
What’s Next For Hospitals And Community Health
Through the development of this measure, several themes have become clear. First, there is broad interest in considering how hospitals can contribute to community health and equity. Second, there is a lack of validated metrics in this area. We chose evidence-based, best-practice standards, but they have not been independently validated. Third, there is a need to support hospitals in responding to their community’s specific health needs beyond traditional community benefit work. Fourth, there is a critical need to evaluate community health impacts at a larger scale to further develop and expand the evidence base regarding best practices and expected impacts of these best practices. A goal of this initial effort is to encourage researchers to focus on such work.
Hospitals can be active partners in promoting community health and equity. As the COVID-19 pandemic makes clear, even the best acute care is insufficient to prevent catastrophic harm and inequity; what’s needed is systematic work to address the social and economic conditions that influence health. Our hope is that this first attempt at assessing hospital contributions to community health with a focus on equity will advance dialogue and spur action, in coordination with communities themselves, about what it means to be a top hospital in the 21st century.
The authors acknowledge Harry Munroe, Jia Ahmad, and Allyson Horstman for their assistance in the development of the hospital measure.