New Orleans, St. Louis, Detroit lead US in racially segregated hospital care, Lown Institute finds

New Orleans stands as the U.S. city with the most racially segregated hospital market, according to a newly released Lown Institute analysis built on 2021 Medicare and Census data.

The think tank found that seven of New Orleans’ 14 hospitals landed on the far upper or lower end of its rankings of U.S. hospitals’ racial inclusivity. It beat out St. Louis, where 43% of its 30 hospitals are considered to be overserving or underserving nearby communities of color, and last year’s front-runner Detroit, where 38% of its 29 hospitals are considered outliers.  

“Hospitals will say their doors are open to everyone and they don’t turn anyone away, but that can be misleading,” Vikas Saini, M.D., president of the Lown Institute, said in a release. “If hospitals really want to undo structural racism’s hold on their communities, they can’t be bystanders. They need to act more systematically and with more intention.”

On the other end of the spectrum, Lown’s analysis highlights 50 of the country’s “most racially inclusive hospitals,” or those with patient demographics that are more diverse than those of the surrounding communities. Boston Medical Center led the pack here, followed by John H. Stroger, Jr. Hospital, UChicago Medicine and Penn Presbyterian Medical Center.

“It’s refreshing to see that some hospitals make caring for those most in need their top priority,” Saini said.

The group’s analysis uses claims data to identify the racial demographics of a hospital’s served Medicare population and compares those to the demographics of its surrounding communities while placing greater weight on closer areas. The most recent version ranked 3,142 hospitals—excluding those with racially homogeneous community areas where a single race comprised 97% of the community—and, for the first time, included Medicare Advantage data alongside traditional Medicare claims.

New Orleans had previously gone unmentioned in the group’s now-annual hospital and city racial segregation rankings; however, other methodology changes in this year’s analysis adjusted the playing field and attributed enough ranked hospitals that marked The Big Easy for inclusion, Lown Institute Senior Policy Analyst Judith Garber said.

For the city-level rankings, Garber said that Lown chose to change over from hospital referral regions (HRRs) to metropolitan statistical areas (MSAs), the latter of which are generally larger and capture more nearby facilities.

“We found there were a couple of different cities that look strange in HRRs, so we decided to try something different this year and use MSA to broaden it just a little bit,” she said.

As for the hospitals themselves, Lown chose to shift from using a “raw score” to a one-to-five-star system when describing hospitals’ racial inclusivity to “make it a little more tangible for readers and reporters to be able to find those one-star and five-stars easier,” she continued.

Relatively few of the hospitals in this year’s analysis were deemed to be outliers on the far side of the grading system—just 3% received the highest five-star rating and 6% the lowest one-star rating. Eleven cities were flagged by Lown as “the most segregated hospital markets” for having more than 20% of its hospitals land either a one-star or five-star rating.

Due to the methodology changes, Garber cautioned against directly comparing the latest rankings to prior years’ results for year-over-year changes. 2022’s release, for instance, had tagged 15 cities with “the most segregated hospital care in America” based on more than half of the hospitals in their HRRs meeting that year’s most or least racially inclusive categories.

However, beyond the larger samples and easier usability, Garber said this year’s review comes with insights on racial segregation in care markets and life expectancy statistics reported by the Institute for Health Metrics and Evaluation. Lown found, for instance, that white residents of St. Louis County live nearly nine years longer than its Black residents, a trend that generally persisted across the 10 other highlighted cities.

Though Garber said the trend doesn’t reveal a “one-to-one” connection between care market segregation and outcomes, “our racial inclusivity metric really shows structural racism in action.”

“Hospitals are not immune to these forces—they’re reimbursed less for publicly insured patients, so they have less of an incentive to care for these populations,” she said. “[Our metric] gets the result that this system is creating. … But you know, even in facing these factors of structural racism, there are hospitals that are going against the tide. Often they're paying for it financially, but they're still doing it, they're still serving their mission and they're serving everyone in their community.”

Garber and Lown also highlighted the inconsistent rankings of prestigious hospitals among the thousands of facilities it reviewed.

Among the hospitals included on the U.S. News Honor Roll, only the Hospital of the University of Pennsylvania was within the top 100 most inclusive hospitals (at #52), while the other end of the spectrum included names Cedars-Sinai Medical Center (#2,948), NYU Langone Hospitals (#2,946), Ronald Reagan UCLA Medical Center (#2,969) and North Shore University Hospital (#2,999).

U.S. News’ annual list in particular has recently faced criticism for methodology choices and other publication practices that some organizations say fuel “perverse incentives” for ranked hospitals. Appropriate valuation of racial equity and conditions affecting underserved populations have been frequent points of contention.

Garber acknowledged that U.S. News is “going in the right direction” with recent steps to develop better equity metrics, but “as far as I know they haven’t actually incorporated it within their rankings” for the Honor Roll hospitals.

“We like to stress that, when it comes to racial inclusivity, a lot of this is not within hospitals control but built up over like decades and decades of policies and residential segregation,” she said. “But it also speaks to the fact that there are some hospitals that are really inaccessible to communities of color—and if these are what U.S. News or others consider some of the best hospitals in the country, especially for certain specialty care, and people of color can't access it, that is a huge issue.”