When hospitals make bad neighbors

IN STATES like Massachusetts, rich with world-renowned hospitals, logic might suggest that people living closest to those health care institutions would be in better health themselves. But a paradox haunts these communities – urban hospitals can hurt the neighborhoods they operate in as much as they help them.

“The big flashy hospitals that everybody thinks about when we think about the largess of American health care – and they have incredible accomplishments happening inside their walls – one of the things we notice is that not only does it not translate to local communities, but hospitals actually turn out to be pretty poor neighbors a lot of the time and actually have negative effects,” Jonathan Wynn, chair and professor of sociology at UMass Amherst, said on The Codcast.  

Wynn and Dan Skinner, associate professor of health policy at Ohio University, explore those dynamics in their 2023 book The City and the Hospital: The Paradox of Medically Overserved Communities.

With the Bay State in the midst of a crisis brought on by the for-profit Steward Health Care system, it could be tempting to think of nonprofit hospital systems as inherently community-oriented alternatives. More than half of US hospitals are nonprofits, with private nonprofits like Massachusetts General Hospital bringing in billions of net patient revenue but off the hook for sizable tax obligations because of their charitable classifications.

The City and the Hospital zeroes in on the Cleveland Clinic in Ohio, Hartford Hospital in Connecticut, and the University of Colorado Hospital in Aurora. Looking at health conditions including heart disease, high blood pressure, diabetes, high cholesterol, and mental illness in the population living in the same census tract as those nonprofit hospitals, Wynn and Skinner found significantly worse outcomes than the surrounding city and national averages. 

Piecing apart the issue involves untangling decades of urban design policy, consolidation of poverty in central urban areas, the logistics of hospital operations themselves, and where public interest spending is directed.

“Yes, poverty does lead to unequal health outcomes,” Skinner said. “But why is it then that you have these premier institutions, these citadels for health, that cannot address those needs? What are the barriers that exist culturally, symbolically, emotionally, socially, that prevent people from having access to it?”

One example Skinner and Wynn point to is interstate highways, which split communities and gutted urban neighborhoods between the 1950s and 1970s. Hospitals tend to be sited near interstates for access reasons. As a start, that means screaming sirens and heavy motor traffic.

“In a way, it’s nice to be located there, but then you start to look at what happened to those communities when they were built,” Wynn said. “So if you go back to the siting and the founding of these places, as geographers know, it’s not a mistake that these places end up in fairly vulnerable communities.” Hospitals, he noted, are “insatiable expanders” that can benefit from superior financial leverage if they want to buy out surrounding land. 

The institutions measuring hospital quality deserve a critical eye, Skinner and Wynn said, noting U.S. News & World Report’s “somewhat famous or infamous rankings” system that is currently the subject of intense litigation. 

The top three Boston-area hospitals by U.S. News ranking– Brigham and Women’s, Mass General, and Beth Israel Deaconess Medical Center – are ranked in opposite order by the Needham-based Lown Institute think tank, which assesses medical institutions on outcomes, value, and equity. While Beth Israel gets an “A” for social responsibility overall, and no Massachusetts hospital scores below an overall “C” in the Lown rankings, Mass General sits near the middle of the Bay State pack – rated very well on value, fairly well on outcomes, but middling on the equity measurement that includes pay and community benefits. 

The American Hospital Association and the Massachusetts Hospital Association take issue with Lown’s assessments, Wynn notes. But hospitals are “famously secretive entities,” he said, with data often “wrested” from them through government action. By objecting to Lown data but resisting full transparency, “there’s an inability to have this conversation in a serious way that I think undercuts all of this,” Wynn said.

Hospitals tout their community benefits contributions and, in Massachusetts at least, tend to be better than other tax exempt institutions like universities at contributing their requested Payment In Lieu Of Taxes (PILOT).

Legislation being considered on Beacon Hill would reform the PILOT system by requiring that institutions exempt from property taxation must pay 25 percent of the amount that would be paid if the property were not exempt.

“I don’t think that the vast majority of what we uncover in this book is because of malignant intent, necessarily,” Skinner said. “I mean, of course there’s gonna be a mixture of things going on, but when you’re that big and when you’re that powerful, and when you’re not paying taxes into school systems and other municipal services and things like that, it’s a public imperative to actually ask what are we getting in exchange for these tax giveaways.”