June 23, 2020

What do the top hospitals on the Lown Index have in common?

A brief analysis of the Top 100 hospitals on the Lown Index.

By Judith Garber

Key Takeaways

  • The Lown Index composite ranking grades hospitals not only on patient outcomes, but also civic leadership and value of care, making it unique among hospital rankings.
  • Larger hospitals, teaching hospitals, and urban hospitals are over-represented in the top 100 hospitals on the Index.
  • Many small rural hospitals, safety net hospitals, and public hospitals also appear on the Top 100 list, scoring even better than some “big-name” hospitals.

What makes a hospital the “best?”

When we think about hospital performance, the first thing that comes to mind is usually patient outcomes. We expect the best hospitals to save patients’ lives and keep them healthy.

But hospitals do much more than care for individual patients; the decisions that hospitals make have a significant impact on community health and equity. Hospitals are often the largest employers in many communities, but some don’t pay their staff a living wage. Other hospitals have expanded their financial aid programs, helping to make health care accessible for all.

While most hospital rankings only include metrics for patient outcomes, the Lown ranking also takes into account hospitals’ community health investments, pay equity, inclusivity, and avoidance of low-value care. In recognition of the importance of patient outcomes, this category makes up the largest percentage of the grade (50%). Civic leadership gets a weight of 30%, and value of care the final 20%.

Which types of hospitals come out on top?

With this novel ranking, we were interested to see which hospitals would come out on top. Would it be the large teaching hospitals with big reputations, that usually win accolades from US News and other rankings? Or would it be the unsung heroes—the safety net hospitals and public hospitals that take in all patients that come through their doors?

The answer is… a little of both. In our examination of the Top 100 hospitals on the Lown Index, we found that the types of hospitals that do well on other rankings (large, urban teaching hospitals) were more likely to be on the Lown Index Top 100 (see Tables 1a&b), although many of the “big names” found on other rankings did not make it into our Top 100. At the same time,  many safety net hospitals, public hospitals, and small rural hospitals also appear at the top of our list.

Table 1a: Hospital types overrepresented on Top 100 list

Hospital type Number of hospitals Actual number in top 100 Expected number in top 100
Major teaching 224 15 7
Minor teaching 810 38 24
Urban location 2120 80 63
Non-safety net 2670 91 79
Medium size 779 32 23
Large size 730 26 22
Very large size 434 23 13
Nonprofit 2811 91 84
Non-critical access 2634 100 78

Table 1b: Hospital types underrepresented on Top 100 List

Hospital type Number of hospitals Actual number in top 100 Expected number in top 100
Non-teaching 2320 47 69
Rural location 1234 20 37
Safety net 692 9 21
For-profit 543 9 16
Very small size 883 7 26
Small size 528 12 16
Critical access hospital 728 0 22

Why are larger, urban, teaching hospitals overrepresented on the Lown Top 100 list? Part of the answer is that large teaching hospitals have been found to provide better care for common conditions and have lower rates of patient mortality compared to smaller non-teaching hospitals. Patient outcomes receive more weight in our final ranking than the other two categories in the Lown Index, and this gives large teaching hospitals a boost.

Hospitals caring for the poorest and sickest patients may appear to do worse on patient outcomes than is actually the case."

Smaller non-teaching hospitals do slightly better on the Lown Index for civic leadership and much better for value of care compared to large teaching hospitals, but not high enough, it seems, to make up for the difference in patient outcomes (see Table 2).

A similar pattern exists with safety net vs non-safety net hospitals. Safety net hospitals serve a larger proportion of patients who are eligible for both Medicare and Medicaid, giving them high marks for inclusivity. Their executives also receive compensation that’s closer to the wages of their average workers. Caring for a larger proportion of poor, less educated, and non-white patients boosts safety net hospitals’ civic leadership scores, but their overall patient outcomes ranking brings down their total score.

The outcomes scores for safety net hospitals might be lower because they have fewer resources to devote to hiring the best doctors, providing clinician training, and initiating quality improvement programs. But safety net hospitals also care for patients with more acute cases of diseases and more chronic conditions, and these patients are often discharged from the hospital into situations where they are less able to get the continuing care they need. A patient who is discharged to an apartment on the fifth floor of a walk up with no grocery store nearby might not do as well as a patient who can hire an aide to help them recover at home. While our clinical outcomes metrics adjust for underlying patient risk, some of these environmental factors and patient conditions may not be accounted for. That means hospitals caring for the poorest and sickest patients may appear to do worse on patient outcomes than is actually the case.

Table 2: Large teaching hospitals vs small non-teaching hospitals in the Lown Index

Hospital type Number of hospitals Average overall ranking Average percentile Civic rank Average percentile Value rank Average percentile Outcomes rank
Large/very large urban teaching hospitals 671 1435 46 37 65
Small/very small non-teaching rural hospitals 868 1986 51 70 30
Safety net hospitals 692 2145 66 61 25
Non-safety net hospitals 2670 1517 46 47 56
Nonprofit hospitals 2811 1608 49 52 50
For-profit hospitals 543 1818 51 39 49

But even though larger hospitals, teaching hospitals, and urban hospitals were more likely to be in the Lown Index Top 100 hospitals, there were many exceptions. Several public safety net hospitals came out on top, as did many small hospitals and rural hospitals (see Table 3). A few of these standouts include:

  • JPS Health Network, a large public safety net hospital in Fort Worth, TX, which snagged the #1 spot on the Lown Index this year with rankings in the 80th percentile or higher in clinical outcomes, community benefit, inclusivity, and avoiding overuse; 
  • Saint Joseph Hospital in Mount Sterling, KY, a rural hospital that has only 42 beds but scored in the top 30% of every category;
  • Boston Medical Center in Boston, MA, a safety net hospital that placed far above the Boston hospitals that usually dominate the US News rankings, with particularly high rankings in community benefit, inclusivity, and avoiding overuse.  
  • Cortland Regional Medical Center in Cortland, NY, a rural safety net hospital with particularly high scores in clinical outcomes, patient safety, and community benefit.

Table 3: Public, safety net, and small rural hospitals on the Top 100 list

Hospital Name and Location Type of Hospital Lown Index Rank
JPS Health Network
Fort Worth, TX
Public safety net 1
Parkland Health and Hospital System
Dallas, TX
Public hospital 10
Boston Medical Center
Boston, MA
Safety net hospital 11
Norton Community Hospital
Norton, VA
Small rural hospital 12
University of CO Hospital Authority
Aurora, CO
Public hospital 18
Harris Health System
Houston, TX
Public hospital 23
Ohio State University Hospitals
Columbus, OH
Public hospital 26
Providence Centralia Hospital
Centralia, WA
Small rural hospital 29
Knox Community Hospital
Mount Vernon, OH
Small rural hospital 38
Hardin Memorial Hospital
Elizabethtown, KY
Public hospital 40
Texas Health Harris Methodist Hospital
Stephenville, TX 
Small rural hospital 41
Oroville Hospital
Oroville, CA
Safety net hospital 45
Saint Joseph Mount Sterling
Mount Sterling, KY
Very small rural hospital 54
Beauregard Memorial Hospital
Deridder, LA 
Very small rural public hospital 57
Munson Healthcare Cadillac Hospital
Cadillac, MI 
Very small rural hospital 63
Cortland Regional Medical Center
Cortland, NY
Rural safety net hospital 66
Metrohealth System
Cleveland, OH
Public hospital 72
Signature Healthcare Brockton Hospital
Brockton, MA
Safety net hospital 75
Mayo Clinic Health System
Austin, Albert Lea MN 
Small rural hospital 81
Plains Regional Medical Center
Clovis, NM 
Small rural hospital 83
Cambridge Health Alliance
Cambridge, MA 
Public safety net hospital 88
Beaufort County Memorial Hospital
Beaufort, SC 
Public hospital 90
Columbus Regional Hospital
Columbus, IN 
Public hospital 95
Baystate Wing Hospital and Medical Centers
Palmer, MA 
Small safety net hospital 100

There is a need for greater pressure on nonprofit hospitals to “earn” their tax benefits with more community health investments and service of Medicaid patients."

The nonprofit vs for-profit debate

The difference (or lack thereof) between nonprofit and for-profit hospitals on the Top 100 is unexpected. Nonprofit hospitals have slightly more representation on the Top 100 list, the difference is very slight. The scores for civic leadership between nonprofit and for-profit hospitals is also surprisingly similar, as are their scores for patient outcomes. The only real difference between them is in the category of value of care, which includes a single component—avoiding overuse—where nonprofit hospitals come out on top.

One would expect a bigger difference between these two types of hospitals when it comes to civic leadership, given that most nonprofit hospitals have a stated mission to invest in community health and are expected to do so by Internal Revenue Service regulations. Yet on the Lown Index, nonprofit and for-profit hospitals are very alike in their scores for community benefit and inclusivity, and only differ in pay equity. Fairer compensation at nonprofit hospitals is encouraging, but it seems there is a need for greater pressure on nonprofit hospitals to “earn” their tax benefits with more community health investments and service of Medicaid patients.

Keep an eye out for more insights as we continue to look at the patterns between Lown Index ranking and hospital type and region! For all of the rankings, head to the Rankings page.