Creating a New Hospital Ranking: Can Health Equity be Measured? (All Slides)

Creating a New Hospital Ranking: Can
Health Equity Be Measured?
Anwesha Majumder & Greta Martin
USN Healthcare Data Scientists

Agenda
● A new research question
● Three approaches to
measuring equity
● Moving towards a new ranking
● Panelist Reactions &
Discussion
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3
Research Question Outcomes Community Benefit Access A New Ranking Discussion

What is health equity? Equity for whom?
WHO definition:
Health equity. Equity is the absence of avoidable, unfair, or remediable differences among
groups of people, whether those groups are defined socially, economically, demographically or
geographically or by other means of stratification.
4

How do hospitals contribute (or not)
to promoting health equity in their
communities?
5

6
“We are here to improve the
health of our community”
“committed to improving the health
status of the communities we serve”
“service to our
communities”
“to improve the health
of our community”
“to improve the health and well-being of
the diverse communities we serve”
“outreach in the many diverse communities we serve”
“serve our community”

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Provider
Bias
Differential
Access
SDOH

Three approaches to the research question
● Disparities in Health Outcomes by Race and SES
○ Inpatient Medicare claims data on deaths and readmissions
● Community Benefit Investment
○ Schedule H data on community benefit spending from 990 tax forms
● Access to Non-Emergent Care
○ Dartmouth Atlas data on ambulatory care sensitive conditions within a Hospital Service Area
(HSA)
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10
Provider
Bias
Differential
Access
SDOH

11
Access to
Non-emergent
Care
Differential
Health
Outcomes
Community
Benefit
Investment

Within a hospital’s walls
12
Outcomes

Racial (in)equity of mortality
13

Socioeconomic (in)equity of mortality
14

Racial (in)equity of mortality
15

Socioeconomic (in)equity of mortality
16

Racial (in)equity of readmission
17

Socioeconomic (in)equity of readmission
18

Quality & Equity
19

Within a hospital’s financial control
20
Community Benefit

Community benefit subcomponents
21

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23

Community benefit to revenue distribution
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Median: 0.21
IQR: [0.14, 0.29]

Bottom 25% of CB to
revenue (N=756)
Top 25% of CB to
revenue (N=770)
Community benefit median % of
hospital revenue (median $)
9.41%
($18.42m)
37.86%
($82.48m)
% metropolitan CBSA 66.21% 65.99%
Median bed count 103 119
% children’s hospitals 0.55% 10.07%
% teaching hospitals 3.83% 10.07%
% dual eligible (inpatient Medicare) 22.64% 32.98%
% Medicaid expansion states 64.57% 75.92%
Characteristics of top and bottom 25%
25
similardifferent

Subcomponents of top and bottom 25%
26
If hospitals in the bottom 25% raised this
to match the top 25% ratio, that would
add another $18 billion in charity care

Financial priorities
27
~30% of non-profit hospitals spent less on charity
care than their single highest paid executive
Bottom 25% of CB to
revenue (N=756)
Top 25% of CB to
revenue (N=770)
Charity care median %
of hospital revenue (median $)
0.82%
($2.17m)
1.46%
($3.15m)
Single highest paid executive median %
of hospital revenue (median $)
0.54%
($1.18m)
0.49%
($1.02m)

Within a hospital’s reach
28
Access

Dartmouth Atlas HSAs
29

30
Source: The data were obtained from The Dartmouth Atlas, which is funded by the Robert Wood Johnson Foundation and the Dartmouth Clinical and Translational
Science Institute, under award number UL1TR001086 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH).

31
Source: The data were obtained from The Dartmouth Atlas, which is funded by the Robert Wood Johnson Foundation and the Dartmouth Clinical and Translational
Science Institute, under award number UL1TR001086 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH).
}
Addressing this
gap would have
resulted in
45,000 fewer
admissions
nationally for
ACSCs in 2015

Geographic distribution
32
Best
Worst

Strengths and weaknesses
33
Approach Strengths Weaknesses
Disparities in Health Outcomes - Patient decision
support
- Attributable to hospitals
- Doesn’t account for
access
- Need sufficient sample
sizes in subgroups
Community Benefit Investment - Potential to impact SDOH
- At hospital’s discretion
- Comparability/validity
of community benefit
dollars
- Tax ID to AHA ID
conversion
Access to Non-Emergent Care - Gets at a hospital’s
ultimate mission
- Attribution of
community factors to
hospital

Moving Toward a New Ranking
34

Panelists
Senior Vice President and
Community Health
Investment Officer,
Northwell Health
Chief Medical Officer,
Sutter Health
Director Emeritus of the
Center for Health Policy and
Health Services Research,
Henry Ford Health System
Associate Professor of
Health Policy &
Management,
Johns Hopkins Bloomberg
School of Public Health
35

A few Cautionary Thoughts
David R. Nerenz, Ph.D.
Director Emeritus, Center for Health Policy and Health Services Research
Henry Ford Health System
Detroit, MI

Disclaimer #1
• The thoughts I express here are my
own – they don’t necessarily reflect
the views of my employer or any
other organization with which I’m
affiliated.

Hospitals and Community Health - 1

Hospitals and Community Health - 2
• Hospitals DO improve
the health of the
communities they
serve, by caring for
people who would die
or suffer long-term
adverse
consequences if they
did not get the special
care that only
hospitals can provide.

Hospitals and ACSCs
• Current State • Future State?
From AHRQ Guide to Prevention Quality Indicators:
Hospital Admission for Ambulatory Care Sensitive Conditions
(2002)

Leadership “Bandwidth” and Opportunity Cost
• An hour spent doing one thing is
an hour not available to be
doing something else.
• A dollar spent on one thing is a
dollar not available for
something else.
• What are the “something
elses”?
• Hospital-acquired infections?
• Other aspects of patient safety?
• Improved functional outcomes?
• Better discharge planning and care
coordination?
• Reducing waste and costs?

Measuring and Achieving Health Equity
• Is this issue important? YES!
• Are there measures that are useful to
identify problems and track progress to
solutions? YES!
• Do measures of health equity fit most
naturally at the levels of community or
defined population? YES
• Should we link these measures to
hospitals and hold hospitals accountable
for community or population health
measures? Hmmmmm

Hospital Community Contributions
Ge Bai, PhD, CPA
Associate Professor of Accounting
Johns Hopkins Carey Business School
Associate Professor of Health Policy & Management
Johns Hopkins Bloomberg School of Public Health
November 19, 2019

46
Hospital Stakeholders
• Patients
• Insurers
• Employees
• Creditors
• Shareholders (for-profits only)
• Tax payers (nonprofit and public only)
• Social and ecological community

47
Ideal Attributes of Performance Measures
• High Congruence + High Sensitivity
 Are we measuring the right thing?
 Are the metrics sensitive to hospital actions?
• Low congruence  Hospitals distort action
• Low sensitivity  Hospitals bear risk
Aggregation and Linearity in the Provision of Intertemporal Incentives. Holmstrom & Milgrom. Econometrica, 1987; 55 (2): 303-328.
Performance Measure Congruity and Diversity in Multi-Task Principal/Agent Relations. Accounting Review, 1994; 69 (3): 429-453.

48
Measure Community Contributions: Broad Approach (IRS Form 990
Schedule H)
Q1: Do they reflect community
contributions to the same
extent?
Q2: Do they include all aspects
of community contributions?
Q3: Are they within hospitals’
control?

49
Schedule H)
extent?

50
Schedule H)
extent?
Q3: Do they all have low
measurement noise?

51
Schedule H)
extent?
Q3: Are they within hospitals’
control?

52
Measure Community Contributions: Narrow Approach
(IRS Form 990 Schedule H)
Charity care at cost
=
Charity care charge written off
X
Cost-to-charge ratio
• High congruence: aligned
with voluntary charitable
missions
• High sensitivity: at each
hospital’s own discretion

53
Variation in Hospital Mission
• Nonprofit: Advance Charitable Mission
 Tax-exempt
• For-profit: Maximize Shareholders’ Wealth
 Pay tax
• Public: Provide Safety Net
 Supported by tax
• Can one metric be used for all hospitals?

Month Day, Year 55
Health Equity…Can it be
Ranked?
Ram Raju, M.D., MBA, FACHE, Senior Vice President,
Community Health Investment Officer
November 19, 2019

The Community Served by Northwell Health
750+ Outpatient Access Points
56

= Outline of all census tracts
inclusive of top 3 zip codes
KEY:
= Southside Hospital
`
= Low Income Housing (Senior)
= Low Income Housing (Family)
= More than 0.5 mi to
Supermarket
= 358 to 596 (26 zip codes)
= 253 to 358 (26 zip codes)
= 213 to 253 (24 zip codes)
= 174 to 213 (26 zip codes)
= 0 to 174 (at/below avg – 29 zip codes)
= 1st or 2nd Quintile on All 5 Social
Determinant of Health
Indicators**
Census Tracts within the Top 3 Zip Codes that have 5 Social Determinants of Health in Quintile 1 or 2 Overlayed on ED T & R
Use Rates per 1,000 and a distance of more than a half mile from the Supermarket
Sources: Low Income Housing - Websites of individual Suffolk County Local Housing Authorities; ED Treat & Release Data - SPARCS ver2017.02.06/tb;
Social Determinant Indicators - 2015 5-year United States Census American Community Survey - https://www.census.gov/programs-surveys/sk; *Zip
Codes are shown with Census Tracts Superimposed; *The following social determinants of health make up this composite indicator:% Non-white, %
Foreign Born, % Less than HS Diploma (Aged 25+), % Unemployed (Aged 16+) and Percent below poverty.
Not surprisingly, the census tracts
with the most social determinant of
health in quartiles 1 and 2 also
have some of the highest rates of
ED T & R Utilization and areas
with distances of more than a half
mile from the supermarket.
57
The Community Served by Southside Hospital: An Example
Putting it All Together

ON A MISSION TO ADVANCE HEALTH EQUITY
Can Health Equity
Be Measured?
Stephen H. Lockhart, M.D., Ph.D.
Chief Medical Officer, Sutter Health

Attribution: Health Equity. 2019 Apr 3;3(1):92-98. doi: 10.1089/heq.2018.0092.
Sutter Health EHR
American Community Survey
– Census 2011-2015
Centers for Disease
Control and Prevention
2014
California Department
of Public Health
OBSERVED
ENCOUNTER
S
EXPECTED
ENCOUNTERS
Sutter Health EHR Data
Calculated Data
2
6
3 HEALTH EQUITY
INDEX
Health Equity Index Inputs

HEI
2.2
Asthma Program
in Alameda County

Salinas Valley Memorial
Healthcare System
HEI for Diabetes
Diabetes Asian Black Hisp White
Male
20-44 0.8 14.7 2.8 3.0
45-64 0.4 1.5 0.8 0.7
65+ 0.4 0.9 0.6 0.5
Female
20-44 0.4 6.2 2.4 2.6
45-64 0.2 1.3 0.6 0.5
65+ 0.4 0.7 0.6 0.4
Health Equity Index (=weighted avg. of HES) 2.2
“The HEI tool allowed us
to identify patients at
greatest risk of having
poor outcomes and
thereby better target
system resources.”
– Peter I. Oppenheim, M.D.
Chief Medical Officer,
Salinas Valley Memorial Healthcare System
DIABETES OUTPUTS

For more information about Sutter Health, visit https://www.sutterhealth.org/about/health-equity
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