A wise medical student once remarked, “rankings are important because Americans like lists.” Magazines promising to provide the low-down on the top 10 songs, best movies, most beautiful beaches, most talented chefs, the top colleges are guaranteed to sell. Lists provide a starting point for people to make decisions when they have many options to choose from. Americans want to believe that in a capitalist society, they should be able to find and pick the best value their budget can afford.
For rankings to be useful, two things have to be true. First, people have to have a choice they can make. Second, the rankings have to measure what is important to people making the choices. Beyond that are pesky details like validity and reliability of the data but let’s just deal with the high level assumptions. Choice and values in health care. Do rankings like US News & World Report’s Americas Best Hospitals help consumers make good choices?
You could argue that patients could use the list to choose the best health care when they need it. But is that reasonable? The methodology for USN&WR Best Hospitals is selected, by their description, to help people choose care for the most serious or complicated conditions. But health care is not a traditional market. Patients with serious or complicated conditions may have little choice. Patients sick enough to need emergency care generally seek (or are taken to) the closest institution, whether or not that institution is tops on any list. People with less emergent but serious conditions may have more choice in theory but in reality, their ability to seek care is heavily constrained by their insurance company’s list of preferred providers (and if they have no insurance—no choice for them!) and by their ability to leave their home community to seek care for a chronic condition (an opportunity that is rare for all but the most wealthy). And what if the patient has more than one condition? Which one should dominate their decision-making about where to seek care?
In reality, when patients receive a serious diagnosis, they are scared and vulnerable and often leave the choice to someone they trust. Under the best circumstances, they will have a longstanding relationship with a physician who understands them as an individual and as a patient with a disease. Under somewhat less optimal conditions, a family member or a neighbor of a patient knows a doctor they can call and ask for a recommendation about where to seek care.
Do the rankings help those physicians make good choices?
Sometimes yes. Reputational measures, the main process measure of the Best Hospital list, assembles the cumulative wisdom of many physicians about where they think the best physicians work. They are a good place to start but, just as with a list of the best songs, different patients will experience people and places on the best list differently. If I am a hard rock fan, I am unlikely to be enthralled by Taylor Swift’s music, even if she is the best female vocalist of the year. If I am a patient who values a caring and compassionate approach but the physicians providing reputational opinions are focused purely on technical skill, I may be similarly disappointed.
What if no one on the list is in your community? What if you don’t have a ‘serious or complicated’ condition but instead, just a nagging condition that is interfering with your ability to enjoy your life? What kind of information can consumers use to pick the best health care system under those circumstances?
-Catherine Lucey, MD