Authors’ correction note: In our post, we may have misled some readers into thinking that US News and World Report’s Annual Best Hospital Guide looks at whether or not hospitals have invested in  proton beam accelerators. The guide does not look at these machines, and the post has been edited accordingly. However, the magazine’s ranking system does reward hospitals for having other advanced technologies, such as positron emission tomography (PET) and computed tomography (CT) scanners. The ranking has no measurement for whether CT or PET or other technologies are being used judiciously—or are even effective in the way they are used.

U.S. News & World Report recently published its annual “Best Hospitals” issue, which the magazine claims is the “global authority in hospital rankings.” That may be no exaggeration, given the more than two million Google results that appear with the search term “U.S. News hospital rankings” along with the flurry of self-congratulatory tweets posted and banners hung each year by the hospitals whose names appear at the top of the list. While the top-ranked hospitals were patting themselves on the back, we wondered if the magazine’s ranking system actually measures what matters to patients, or for that matter to anybody who is worried about the cost and quality of US health care. So we took a closer look at how U.S. News measures hospital quality and—just as important—what factors its analysis leaves out.

Treating Specialty Care As Beauty Contest

According to its detailed methodology report, the U.S. News & World Report’s ranking places much more weight on hospitals’ performance in specialties and on serious or complex medical procedures than on care for chronically ill patients, the population that makes up the bulk of hospitalizations. Of the 448 total points a hospital can get toward its total “Honor Roll” score, 340 points come from specialty scores. Within the specialty scores, only outcomes from “challenging or critical” procedures are included. While this could be helpful for the few patients who can actually shop around for a hospital for a complex procedure or problem, the overall rankings could be misleading for the majority consumers, most of whom will be hospitalized not for specialty procedures but rather for exacerbations of such chronic illnesses as heart failure and diabetes.

More than 25 percent of each specialty score comes from expert opinion, measured by a survey of physicians. The survey asks doctors to supply the names of up to five hospitals in their specialty that provide the best care to patients with serious conditions. In past years, some have argued that the emphasis on expert opinion turns the ranking into a popularity contest. In 2010, the U.S. News rankings aligned almost exactly with rankings based solely on reputation, and a 2017 study confirmed that reputation had a larger impact on hospitals’ scores than more objective measures. The magazine has disputed these charges, but apparently hospitals themselves seem to think this part of the ranking methodology matters. They try to influence their scores by encouraging their physicians to sign up for Doximity, the physician membership organization U.S. News samples from for its survey.

No Consideration Of Cost And Waste

Cost of care is a conspicuous oversight in the U.S. News ranking system. Nowhere does the ranking reward hospitals’ efforts to cut unnecessary services, improve efficiency, or accept alternative payment models. In fact, the physician survey explicitly asks doctors to recommend hospitals without considering cost. A ranking that takes money into account could incentivize hospitals to improve efficiency and rein in the prices they charge, both of which could bring down the cost of health care for everyone.

Many aspects of the U.S. News ranking system encourage, rather than punish, the delivery of unnecessary services (also called low-value care). Hospitals receive a small amount of credit (5 percent of each specialty score) for avoiding preventable complications, but they get no points for avoiding low-value care. They get no points for making sure patients are well-informed about their choices of treatment and actually want the treatment they get, especially at the end of life.

The ranking system also rewards hospitals for having more advanced technologies, such as positron emission tomography (PET) and computed tomography (CT) scanners, but has no measurement for whether these technologies are being used judiciously—or are even effective. Access to certain technologies such as PET and CT scanners can be beneficial but are also easy to overuse, driving up unnecessary testing and unnecessary costs.

The U.S. News rating rewards the hospitals that can perform the most complex and risky procedures without harming the patient but does not address the question of whether hospitals should perform these procedures. For example, the following is included on U.S. News’s Frequently Asked Questions page as a way patients could use the rating system:

Someone in his 80s or 90s with pancreatic cancer would be one of many examples. Most hospitals would reject him as a patient—as indeed they should if their surgeons lack the expertise to remove the cancer without harming the rest of the fragile pancreas. But multiple investigations by U.S. News have found that some hospitals without the requisite skills would go ahead, possibly at considerable risk. He would be better served by one of the hospitals in the Best Hospitals cancer rankings, many of which see a steady stream of patients like him.

Granted, it would be better for this hypothetical patient to have the surgery at a hospital with experienced instead of unskilled surgeons. But nowhere does the ranking acknowledge the idea that surgery might not be the right treatment for this patient.

What About Social Mission?

In 2010, a group of health policy and community health researchers created a new framework for ranking medical schools—based not on research funding or school selectivity, but rather on fulfillment of its social mission. For each school, researchers measured the proportion of underrepresented minority graduates, graduates practicing primary care, and graduates practicing in underserved areas. Their study highlighted the inadequacy of mainstream rankings in measuring medical education’s contribution to improving health care and population health.

Similarly, the U.S. News rankings fall short of evaluating hospitals’ social mission. There is no examination of how much a hospital gives back to its community through funding local nonprofits, no information on whether it has a free clinic and how many community members are served, and no statistics on the proportion of women or people of color on staff. Besides a brief mention of translation services, there are no criteria at all for community services. And one has to question U.S. News’s failure to consider social mission when the hospital ranked second best in the country is chastised for leaving its surrounding community impoverished and unhealthy.

Hospital rankings have the potential to change hospital practices, for better or for worse. As we attempt to transform our health care system to provide higher-value care, we need a ranking system that helps hospitals move toward that goal. We need a ranking system with a different definition of “best” hospitals. One that doesn’t rely on reputation among physicians, includes multiple risk-adjusted outcomes, and takes cost of care, social mission, and high-value care into account.