The coronavirus pandemic and unrest after the death of George Floyd were painful reminders of deep racial inequality in the U.S. health-care system and led to renewed calls for change.
Hospitals, the epicenter of pandemic response in many communities, have responded with a range of initiatives, many of which began years ago: bias training for doctors and executives, accelerated hiring plans to diversify care teams, outreach programs to forge stronger connections with underserved communities.
But whether any of it will mean better care for people of color, improve patient trust, or reduce racism in the health system is an open question.
A new report by the Lown Institute, a Boston-area health-care think tank founded by cardiologist and Nobel Peace Prize recipient Bernard Lown, represents an effort at measuring how well hospitals are serving patients of color by ranking them based on racial inclusivity — how well their patient population reflects the demographics of the community they serve.
After evaluating more than 3,200 hospitals, researchers concluded that while many have made progress, many more have a long way to go in serving diverse communities. Philadelphia and other metropolitan areas, where people have more choice of where to go for care, were particularly prone to appearing segregated, with some hospitals disproportionately serving patients of one race or another, researchers found.
The Lown Institute Hospitals Index has shortcomings: Rankings are based on 2018 U.S. Census and Medicare data, which might not reflect today’s complete reality. And ranking individual hospitals that operate as part of a larger system may offer an incomplete picture of all the resources available to patients, hospital executives said.
But the study helps set in motion a necessary shift in how hospitals are making the kind of cultural transformation that much of society is facing as Americans come to terms with the legacy of systemic racism, researchers said.
“Hospitals reside in communities and are part of communities. Our view is they shouldn’t just serve a community, they should genuinely be part of a community,” said Vikas Saini, a physician and president of the Lown Institute. “A lot of the contemporary rankings that look at reputation or mortality, surgical complications, don’t capture that dimension. We set out to create a lens through which to view the hospital system that’s different.”
While patients’ feedback on their care is an increasingly important metric in hospital ranking systems, most traditional reports still rely heavily on more quantitative measures, such as infection rates, mortality, and surgical outcomes.
The Lown report compared the race demographics of hospitals’ Medicare patients to the Census demographics of their service area. Hospitals whose Medicare patient population had a similar racial makeup as their community ranked in the middle, scoring around 1600. Hospitals that served a greater proportion of Black patients than live in their community were deemed the most inclusive, and ranked at the top of the list. Those serving a far smaller portion of Black individuals relative to their community population ranked lowest.
“It’s not that Black people aren’t getting hospital care — they are — but for every hospital that’s tilted one way, there’s another that’s tilted the other,” Saini said.
Equity and choice
So why does that matter? After all, can hospitals really control who chooses to come to their facilities?
“If we truly want to focus on building a culture of health, yes, personal choice matters. But the choices we make depend on the choices we have, and for so many in America those choices are not equitably distributed,” said Richard Besser, president and CEO of the Robert Wood Johnson Foundation. Besser spoke during a panel discussion organized by the Lown Institute.
Black individuals are often making health-care decisions “from a constricted set of choices,” said Harriet Washington, a medical ethicist and author, who also participated in the Lown panel.
Lack of insurance, a friend’s or family member’s negative experience, the general perception of how people of color are treated when they seek care are all logical reasons for people to choose one hospital over another, Washington said.
“There are lots of reasons why people make choices, and they’re not always obvious,” she said. “That question is indicative of one of the larger issues in U.S. health care — the tendency to scrutinize the behavior of the underserved, when we should be scrutinizing the behavior of health-care systems.”
The Philadelphia area ranked among the metro regions with the most segregated hospitals, with 78% of hospitals falling either in the top 50 most inclusive or bottom 50 least inclusive -- meaning their patients are disproportionately Black or white.
Temple University Hospital ranked 13th most inclusive, while Bryn Mawr Hospital ranked among the bottom 50.
“I was sick to my stomach,” said Main Line Health CEO Jack Lynch, whose system includes Bryn Mawr. “I found it to be completely inconsistent with what we’re doing. Not that we don’t have further to travel, but I feel good about where we’re going.”
He pointed to the health system’s efforts to diversify its board, leadership, and staff, as well as its recent partnership with Black churches to encourage more people to get the COVID-19 vaccine.
Lynch took issue with the report’s use of Medicare data alone, which researchers say they used because that is what they had access to and because payment rates are more uniform than private insurance.
Main Line’s Medicare population is not representative of the hospital’s total patient population, he said. At Bryn Mawr, for instance, 9.4% of all patients are Black, while only 7.4% of Medicare patients identify as Black. The hospital’s service area is 9.8% Black, he said. Asian and Hispanic patients also tend to be younger (most Medicare patients are 65 and older), while nursing homes with predominantly white residents skew the Medicare population, he said.
PJ Brennan, the chief medical officer at Penn Medicine, said a hospital’s ranking in the Lown report may also have been influenced by the type of institution it is. For instance, Pennsylvania Presbyterian Hospital ranked 61st in the report, while eight blocks away in West Philly, the Hospital of the University of Pennsylvania fell in the middle — its Medicare population more or less resembles the community. In Center City, Pennsylvania Hospital ranked 2,822 — serving far fewer Black patients than live in the service area.
Presbyterian Hospital “serves that immediate community to a greater extent than HUP does because of the complexity of care HUP serves,” Brennan said. Meanwhile, Pennsylvania Hospital is known as a local hub for obstetric care in a city that has lost numerous maternity wards over the years and draws patients from the Pennsylvania suburbs and South Jersey.
Ownership consolidation could also lead to greater inclusivity at hospitals in Philadelphia. Penn Medicine is part of a partnership that took over services at Mercy Philadelphia Hospital, a safety-net facility in West Philadelphia.
The closure of Hahnemann Hospital has meant more patients of color at Pennsylvania Hospital and Jefferson, Brennan said.
Others may be traveling up Broad Street to Temple University Hospital, a provider that, according to the Lown report, treats more Black patients than live in the immediate area.
Temple has built trust among its neighbors by asking them what they need and what they think the health system should improve, said Tony Reed, Temple’s chief medical officer. Hiring from within the hospital’s service area has helped, too.
“We don’t always have the providers out and about in the streets, and it’s impossible to meet 200, 300 people anyway,” Reed said. “It’s not that one-on-one interpersonal trust, it’s the overarching reputation — how we perform on an everyday basis. For the people who choose to come to us, it becomes word of mouth.”
The coronavirus pandemic was an opportunity to deepen relationships, Reed said.
Hospital leaders worked with community members, smaller clinics, and social workers to tailor a vaccine message that resonated with residents. They quickly found that their initial message of “fighting COVID” and “combating the virus” by getting vaccinated didn’t inspire people to get the shot. Advertising that described getting vaccinated as a personal responsibility to family and community landed better.
“Culture matters,” said Eve Higginbotham, vice dean of inclusion and diversity at the University of Pennsylvania’s Perelman School of Medicine. “If I’m walking into a primary care doctor’s office, I’m going to make a choice based on how I feel. It is the responsibility of the hospital to create a culturally receptive environment.”
To improve the health of their communities, diversity experts say, hospitals must first improve their own health, by taking a tough and honest look at how they treat patients of different backgrounds. For instance, providers may refer patients for follow-up care or recommend treatment based on what they perceive as their patients’ ability to manage or afford it, creating a bias that might harm their care.
“Cultural humility” training was made mandatory for all Penn employees, Higginbotham said — a key first step in creating a more welcoming culture.
Higginbotham said she was not surprised by the Lown report’s findings. She hopes future versions will consider how hospitals within a large system work together to care for patients, and how all patients — not just Medicare patients — are treated.
“It’s a good starting point that gives us fodder to reflect on how we’re doing and how we can all do better,” she said. “Philadelphia is one of the most diverse cities in the top 10 [largest] but also has the highest proportion of people in poverty — we have to find ways to enhance population health.”