San Francisco city attorney questions legality of U.S. News and World Report hospital rankings

San Francisco City Attorney David Chiu has sent a letter to U.S. News & World Report today seeking information on the company's hospital rankings, which have come under scrutiny from medical experts for alleged imprecise methodology and bias.

The letter also demands that U.S. News publicly disclose the payments it receives from the hospitals it endorses, as required by federal regulations.

"Consumers use these rankings to make consequential healthcare decisions, and yet there is little understanding that the rankings are fraught and that U.S. News has financial relationships with the hospitals it ranks," said Chiu.

"The hospital rankings appear to be biased towards providing treatment for wealthy, white patients, to the detriment of poorer, sicker, or more diverse populations," he said. "Perverse incentives in the rankings risk warping our healthcare system. Hospitals are treating to the test by investing in specialties that rack up the most points rather than in primary care or other worthy specialties."

WHAT'S THE IMPACT?

U.S. News' hospital rankings tend to draw the attention of the healthcare community. According to Chiu, the paper encourages patients to follow its hospital rankings even over physician referrals, and claims "the hospital the doctor suggested for you might be right for you – but maybe not."

Although U.S. News does not state how many people visit its online hospital rankings specifically, it claims that more than 40 million people visit its website every month, with others buying its annual "Best Hospitals Guidebook."

But Chiu is claiming that the data and methodology behind the hospital rankings are unreliable or imprecise at best. According to his office, U.S. News uses data not intended or appropriate for assessment purposes to formulate the rankings. In some areas, the rankings are based on a small subset of patients and exclude data from treatment of lower-income patients, like Medicaid patients. 

Peer opinion surveys play an outsize role in rankings, he said, and in some specialties the rankings are based entirely on peer opinion surveys.

What that does, alleged Chiu, is create perverse incentives for hospitals to invest in areas that score more points in the rankings instead of investing in primary care, other specialties, or ways to reduce the costs of care.

Another allegation in the letter is that, in some instances, U.S. News weights treatment for conditions experienced primarily by white people over treatment for conditions experienced primarily by people of color. By way of example, Chiu said that in the children's hospital rankings, U.S. News gives disproportionate weight to cystic fibrosis treatment, experienced by 1 in 3,500 white Americans, over sickle cell disease, experienced by 1 in 365 Black newborns.

Additionally, U.S. News allegedly receives revenue it does not disclose from hospitals it ranks. By failing to do so, Chiu said U.S. News appears to be violating FTC regulations requiring the disclosure of a material connection between an endorser and the subject of an endorsement.

U.S. News receives revenues from hospitals through licensing fees to use its "best hospitals" badge, subscriptions to access the granular data underpinning the rankings, and advertising on its website and in the Best Hospitals Guidebook, according to the city attorney's office. This funding is significant. One hospital in Kansas allegedly acknowledged that it paid US News $42,000 to use the "best hospitals" badge for one year.

Smaller, rural, or community hospitals do not have the resources to compete in the rankings. This, said Chiu, creates a cycle in which patients and research funding flow to higher-ranked hospitals instead of smaller, community hospitals. Those smaller hospitals continue to be under-resourced and do not perform well in the rankings, or are not ranked at all, the city attorney said.

U.S. News did not immediately return a request for comment.

THE LARGER TREND

St. Luke's University Health Network, based in Pennsylvania and New Jersey, recently announced that the network would no longer participate in U.S. News rankings, citing similar concerns to those raised in the city attorney's letter.

The letter to U.S. News from St. Luke's says the rankings rely heavily on surveys of doctors, essentially making the rankings a "popularity contest," when they should instead be based on objective metrics.

St. Luke's alleged the rankings fail to consider the cost of care and don't appropriately weigh patients treated for chronic illnesses. The health system also said that mortality rates are given undue weight. 

In his letter, the city attorney demands U.S. News substantiate its advertising claims, explain its methodology and how it intends to correct biases, and immediately publicly disclose the revenue it receives from hospitals.

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com