Racial minority patients underrepresented in 80% of hospitals, U.S. News “equity measures” find

The vast majority of hospitals in the United States—up to 80%—treat patient populations that are disproportionately white, U.S. News & World Report said, unveiling a new  suite of health equity measures earlier this week.

“At roughly 4 out of 5 U.S. hospitals, racial and ethnic minorities are underrepresented among patients who access many common services … at more than 1,400 hospitals,” U.S News health analysts wrote in a July 27 editorial.

The finding stems from new health equity metrics—part of the largest expansion of decision-support services offered by U.S. News in over a decade—that now accompany the online descriptions and ratings of most healthcare institutions listed in the 2021-2022 Best Hospitals rankings.

Experts agree that these institution-specific equity scorecards should be used to inform the iconic U.S. News rankings of hospitals. The U.S. News assessment is unprecedented in visibility, scale, and character, said Ben Harder, managing editor and chief of health analysis at U.S. News.

The new measures weren’t used in the rankings this year, but should that change, the existing rankings of cancer centers would likely change as well. Institutions where racial minorities are underrepresented may slide down in the pecking order.

The health equity data, which appears alongside overall and specialty care ratings, can be accessed by scrolling to the bottom of U.S. News profile pages for each evaluated hospital.

“I could not find any study that looked as broadly at elective care as we have,” Harder said to The Cancer Letter. “This is also the first time, to my knowledge, that data like these have been reported for each individual hospital, not just the nation as a whole.”

A conversation with Harder appears here.

The U.S. News health equity suite largely relies on inpatient Medicare data from 2015 through 2019 to evaluate more than 1,900 hospitals, primarily by comparing the racial demographics of patients to community benchmarks—in other words, the actual diversity within each hospital’s service area.

Patients can now use the health equity measures to make informed decisions about their choice of hospital, Harder said.

“We want to understand which hospitals are providing the care that their population needs and achieving good outcomes for everyone in their community, and not just for those who may find it easier to access care or may be diagnosed earlier,” Harder said. “We want to provide decision support—essentially data-driven information that patients can use to make more informed decisions.”

Republished with permission from U.S. News & World Report

Harder didn’t say when the metrics would be used in the rankings.

“We look forward to having conversations with equity researchers, patient advocate groups, with healthcare organization leaders, about what we have measured and what remains to be measured, and how those measures might fit into our future rankings,” he said.

Key findings from this year’s U.S. News analysis, which focus on access, include:

  • Only 29% of hospitals treated a proportion of Black patients that was comparable or higher than the proportion of Black residents in the hospitals’ service areas.
  • Only 18% and 5% of hospitals met that bar for Hispanic and Asian/Pacific Islander patients, respectively.
  • Medicare-insured residents who are Black, compared to similarly insured residents of other races, have experienced more hospitalizations that might have been avoidable if they’d had access to better preventive health care.
  • The racial gap in potentially preventable hospitalizations grew worse since 2011 in nearly a third of U.S. communities, despite incentives for hospitals in the 2010 Affordable Care Act to invest in improving the health of local populations.

In addition to gauging access, Harder and his team intend to expand the health equity suite to include measures on:

  • Outcomes: Results of hospital care, which may include death, preventable hospital admissions or readmissions, and other consequences, and
  • Social determinants of health: How hospitals, as institutions, contribute to and invest in reducing social inequities in the communities that they serve. 

To comprehend the significance of disparities articulated in the U.S. News study and define the scorecards’ impact on bragging rights at cancer centers, The Cancer Letter asked four leaders in oncology to evaluate the health equity measures:

  • “More health systems are in need of a health equity report card like we use in quality and safety. I am looking forward to the day when these health equity report cards are widely used, by most if not all health systems,” said Robert Winn, director of Virginia Commonwealth University Massey Cancer Center and president-elect of the Association of American Cancer Institutes.
  • “Having just stepped away from leading cancer care at a major safety-net hospital, I would say yes—health equity is, in my opinion, something that is reasonable to consider in the evaluation of hospitals,” said Karen Knudsen, CEO of the American Cancer Society and former enterprise director of Sidney Kimmel Cancer Center at Jefferson.
  • “The USNWR rankings are both highly visible, but also impactful in everything from marketing cancer care, to attracting faculty, to contracting with third-party payers. USNWR would likely increase the emphasis and corresponding resources that institutions would devote to these efforts and the inclusive outreach of their cancer care in their respective communities,” said Ruben Mesa, executive director of Mays Cancer Center at UT Health San Antonio MD Anderson.
  • “I do believe that the fact that all patients assessed were insured by Medicare, make the disparities and outcome differences seem even more profound. And yes, I am sure that when individuals insured by Medicaid, the Medicaid Waiver, private insurance, and uninsured patients are examined, the differentials and disparities in patients served and outcomes will be tremendous and concerning,” said Cheryl Willman, director and CEO of University of New Mexico Comprehensive Cancer Center, incoming executive director of Mayo Clinic Cancer Programs, and incoming director of Mayo Clinic Comprehensive Cancer Center.

Full responses from Winn, Knudsen, Mesa, and Willman appear here.

Cancer centers focus on disparities

Many top-tier U.S. academic cancer centers  have conducted in-depth analyses of their catchment areas, thanks to existing review processes for NCI designation.

“That does happen for all [71 of] the NCI designated cancer centers,” Knudsen said to The Cancer Letter. “It’s one of the things you report in the peer reviewed way to the NCI—here is the demographic and distribution of our catchment area. Here’s who’s coming in the door. 

“And so, when there’s the gap there, quite justifiably, we as cancer centers hold each other to the mat and say, why? What is the reason why there’s this group in your area that’s not coming in for cancer care? And if there is a gap, what are you doing about it? This is why I feel very comfortable saying that the cancer centers are making major efforts within the limitations of the resources that they have. But I don’t think that they can close the gap alone.”

Also, efforts are underway at a majority of North American cancer centers—AACI member institutions—to characterize catchment areas and identify major cancer disparities within their respective regions. 

The two-step process was established through a 2020 AACI presidential initiative led by Knudsen before she joined ACS (The Cancer Letter, Oct. 16, 2020).

“The survey data from the cancer centers came back, and we had 100% compliance with the AACI centers to give us their data. The manuscript is written, actually, to completion. It’s really interesting,” Knudsen said. “The second wave has already begun, which is saying to the cancer centers, please let us know about the major cancer disparities that you identify within your region.

“We put out a survey to all the centers that gave them a list and asked them to rank order—what are the things that are the highest priority in your area? And then we asked the cancer centers to tell us two things. One, tell us a win, something that was successful, an implementation, some sort of intervention in your catching area that was successful in reducing a cancer disparity, because we’d like to learn from each other about what’s been possible. We also asked them to tell us one area of consternation, something that you’ve thrown resources at, that you’ve had an intervention.

“So, we’re waiting for all those to come back. I can’t wait to see what those data look like. I think they will be incredibly instructive and informative for us as a cancer community. And for the first time, I think will illustrate where major gaps lie and where cancer centers are truly struggling.”

To address these challenges, several cancer center directors are banding together to cross-pollinate on equity initiatives.

“Dr. Robert Winn and I have been working to gather a group of similar minded NCI Designated Cancer Centers, to join the Mays Cancer Center in San Antonio and Massey Cancer Center at VCU, to develop a collaborative effort to advance Cancer Health Equity across our communities, our states, our country,” Mesa said. “We look forward to sharing more with The Cancer Letter as these efforts mature.”

A change in the rankings?

If the U.S. News health equity metrics are used to inform hospital rankings, how would the data affect the Best Hospitals hierarchy of cancer centers?

It’s too early to tell, for several reasons:

  • In this inaugural iteration, the data appear to describe each hospital or health system en bloc, which may not be representative of patient demographics within individual specialties or departments, e.g. cancer centers in matrix institutions. Also, there is no breakdown of data by treatment modality e.g. cancer surgery.
  • It’s unclear whether data for freestanding cancer centers can be interpreted as representative of the institutions’ performance on cancer health equity.
  • The existing health equity measures, while useful, are primarily characterized according to inpatient Medicare data, which represent a sliver of patients who seek treatment at cancer centers. The largest share of cancer treatments occurs in outpatient settings, which aren’t included in the U.S. News analysis.
  • It’s not publicly known how health equity would be weighted in the rankings framework.

U.S. News would need to collect and process comprehensive inpatient and outpatient data specific to the cancer patient population in order to weigh health equity in its ranking of cancer centers. 

As it stands, the existing health equity measures developed by U.S. News are built on five data sources: 

  • Dartmouth Atlas Project—Primary Care Access Measures and Hospital Service Area Crosswalk,
  • Medicare administrative claims—Inpatient Limited Data Set Standard Analytical Files (Inpatient LDS SAF), 
  • American Hospital Association annual survey,
  • American Community Survey and County Population Estimates, and
  • ZIP Code to County Crosswalk, available through the U.S. Department of Housing and Urban Development.

A detailed breakdown of the U.S. News methodology for the health equity measures is posted here.

While U.S. News’s reliance on Medicare data could be characterized as a limitation of the health equity analysis, Harder argues that it eliminates some confounding variables.

“I think it’s also a strength of our analysis in that by focusing on just the Medicare population, we take the effect of not having insurance out of the equation,” Harder said. “So, you would expect, since everyone we’re looking at has the same insurance plan, that we should not see disparities in access. Yet, we do.”

Harder and his team assessed equity across eight measures: 

  • Five on elective care, which describe representation according to major racial and ethnic groups, and
  • Three on preventive care, which assess the effectiveness of preventive care for Black residents (in a hospital’s service area) in reducing potentially avoidable hospitalizations.

The assessments are characterized according to intervals, which correspond to labels that indicate the degree to which representation of minorities are, for example, “comparable to” or “lower than” the community.

For  illustration, see Figure 1, a screenshot of the elective care section for Memorial Sloan Kettering Cancer Center.

Figure 1: Elective Care Measures for Memorial Sloan Kettering Cancer Center

Similar intervals are applied to the preventive care measures, which are assessed as e.g. “less equitable” or “equitable” for Black residents. Figure 2 is a screenshot of the preventive care portion of the health equity suite for UCSF Medical Center.

Figure 2: Preventive Care Measures for UCSF Medical Center

Although these data may not necessarily be representative of cancer patient populations, the 2021-22 health equity assessments for hospitals ranked according to excellence in cancer care might be worth looking at.

The top 11 are: MD Anderson Cancer Center, Memorial Sloan Kettering Cancer Center, Mayo Clinic, Dana-Farber/Brigham and Women’s Cancer Center, Cleveland Clinic, Johns Hopkins Hospital, Northwestern Memorial Hospital, UCLA Medical Center, Cedars-Sinai Medical Center, Hospitals of the University of Pennsylvania-Penn Presbyterian, and UCSF Medical Center.

Of these institutions, only Dana-Farber lacked an equity scorecard. Across the remaining 10:

  • Black patients are consistently underrepresented.
  • At hospitals with available or sufficient data on Hispanic patients, this population is underrepresented.
  • At three hospitals—MD Anderson, MSK, and Johns Hopkins—Asian/Pacific Islander patients are represented at levels “comparable to or higher than the community.” 
  • Only MSK is rated “comparable to or higher than the community” for overall “representation of non-white patients.”
  • Only UCSF is rated “equitable for Black residents” on a measure that compares the rate of potentially preventable hospitalizations among Black residents in this hospital’s service area to that of residents nationwide.

“I really think many of the barriers are beyond the cancer centers. Now, it doesn’t absolve them of responsibility. They certainly have a role to play, and I’m not saying that there’s no room for further improvement,” ACS’s Knudsen said. “But I don’t know that there’s any cancer center director that goes to bed at night and feels that they have the resources to do everything they need to do to bring in equitable service and equitable access to care.

More health systems are in need of a health equity report card like we use in quality and safety. I am looking forward to the day when these health equity report cards are widely used, by most if not all health systems.

Robert Winn

“Reimbursement has quite a lot to do with it. So, if you just look dispassionately and objectively at the data, we understand very clearly that areas where there’s been Medicaid expansion have then seen better cancer outcomes. There’s a clear correlation there,” Knudsen said. “That’s beyond, for example, the level of the cancer center. Having access to coverage and basic cancer care is obviously critical for that to work and for the community to be represented within any given health system or hospital.

“The U.S. News & World Report data are a good basis for us to have this conversation. I applaud them for doing it. I think it’s a good plan for us to move towards this and start the dialogue.”

U.S. News intends for the just-published health equity data to compel healthcare executives to focus on disparities.

Said Harder:

“I think the time is now. The time has been now for a long time when it comes to disparities in health care.”

This story is part of a reporting fellowship on health care performance sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.