Health Equity Ratings of U.S. Burn Centers—Does For-Profit Status Matter?

Abstract

Achieving health equity is forefront in national discussions on healthcare structuring. Burn injuries transcend racial and socioeconomic boundaries. Burn center funding ranges from safety-net to for-profit without an understanding of how funding mechanisms translate into equity outcomes. We hypothesized that health equity would be highest at safety-net facilities and lowest at for-profit centers. All verified and non-verified American Burn Association burn centers were collated in 2022. Safety-net status, for-profit status, and health equity rating were extracted from national datasets. Equity ratings were compared across national burn centers and significance was determined with comparative statistics and ordinal logistic regression. On an equity grade of A–D (A is the best), 27.6% of centers were rated A, 27.6% rated B, 41.5% rated C, and 3.3% rated D. About 17.1% of all burn centers were designated as for-profit compared to 21.1% of centers that were safety-net. About 73.1% of safety-net centers scored an A rating, and 14.3% of for-profit centers scored an A rating. Safety-net centers were 21.8 times more likely (P < .001) to have the highest equity score compared to nonsafety-net centers. There was an 80% decrease in the odds of having a rating of A for for-profit centers compared to nonprofit centers (P = .04). Safety-net centers had the highest equity ratings while for-profit burn centers scored the lowest. For-profit funding mechanisms may lead to the delivery of less equitable burn care. Burn centers should focus on health equity in the triage and management of their patients.

INTRODUCTION

There is urgent need to improve health equity across the world, and burn care is no exception. A recent systematic review demonstrated multiple examples of Black and Hispanic patients achieving worse outcomes following burn injury.¹ Burn injuries affect people indiscriminately, and it is crucial that patients with burn injuries receive the care they need regardless of their social determinants of health—including race, ethnicity, sex, and socioeconomic status.² For decades, institutions such as the World Health Organization, Centers for Disease Control and Prevention, and the United States Department of Health and Human Resources have been developing commissions, forums, and reports to mediate and investigate differences in health disparities.^2–5 A 1980s report showed that there were significant differences in health outcomes based on race and ethnicity.^4,6 Besides race and ethnicity, education level, sex, sexual orientation, and socioeconomic status, among other factors, are well known to modify the healthcare received, specifically with marginalized groups receiving poorer healthcare outcomes.⁷ Health disparities are universal, affecting both the developing and developed world.⁸ In order to improve health equity, it is imperative that data demonstrating health inequity is unambiguously presented so discreet changes can be made to ensure equitable healthcare delivery for all.^9–12

The delivery of healthcare in the United States is influenced by funding mechanisms.^13,14 Contracted rates for Medicare and Medicaid are significantly lower than commercial insurance rates, which leads many facilities and providers to limit or avoid public payers.¹⁵ This is particularly salient with for-profit hospitals that attempt to maximize margins and profits. While patients cannot be denied life-saving care in an emergency under protection of the Emergency Medical Treatment and Labor Act (EMTALA), many burn patients are transferred from other facilities, and hospitals may decline transfer without violating EMTALA if no bed is available.¹⁶ When considering that many Medicaid patients are racial and ethnic minorities, facilities that avoid these payers may inadvertently avoid treating non-White patients.¹⁷

Facilities that contain burn centers have variable funding mechanisms including nonprofit and for-profit. In addition, some centers are part of institutions that have safety-net designation in caring for a large proportion of low-income and minority populations. There are no reports to our knowledge that describe funding mechanisms of burn centers by region/state. Furthermore, no investigations have attempted to characterize variation in health equity between centers. We hypothesize that funding status influences health equity outcomes, specifically that safety-net centers are more likely to have higher equity scores compared to non-safety-net centers, and for-profit centers are less likely to have higher equity scores compared to non-for-profit centers.

METHODS

Dataset and variables

We collated a list of all verified and non-verified burn centers as equipped by the American Burn Association (ABA) and listed by Burn and Reconstructive Centers of America as of February 2022. For-profit status, safety-net status, and health equity ratings were extracted from publicly available data provided by the Lown Institute.¹⁸ The Lown Institute, described as a nonpartisan think tank advocating bold ideas for a just and caring system for health, provides publicly available data to better the U.S. health system.¹⁸ In an effort to make health inequity more transparent, they calculate parameters such as a health equity score, and note whether healthcare centers are for-profit or safety-net.¹⁸ Multiple peer-reviewed investigations have be published within the past few years using the Lown data.^19–22

The equity category within the Lown dataset is comprised of three components: community benefit (charity care, Medicaid revenue, and community investment), inclusivity (by race, income, and education), and pay equity (executive compensation vs worker compensation). These components were weighted in a ratio of 2:2:1, respectively, to generate a health equity score for hospitals. Health equity scores ranged from A to D, with an A score defining the best.

Analysis

We conducted Fisher’s exact analyses to analyze associations between health equity scores and Burn and Reconstructive Center of America status, for-profit status, safety-net status, and ABA verification status. Of note, centers may have multiple statuses (for example: a center can be both Burn and Reconstructive Centers of America and ABA verified). These designations were geo-mapped and charted for comparisons. Given that our outcome was an ordinal categorial variable, we performed an ordinal logistic regression, where the units of analysis were all health equity scores. The model speculations were:

log (P(health equity score)) = intercept + ß₁ ABA_status+ ß₂ SN_status + ß₃ FP_status + ß₄ BRCA_status + residual/error

SN: Safety-Net Center; FP: For-Profit Center; BRCA: Burn and Reconstructive Centers of America.

The exp(ß₁) represents the odds of an ABA verified center receiving a health equity score of A over the odds for a non-ABA-verified center receiving a health equity score of A holding safety-net status, for-profit status, and Burn and Reconstructive Centers of America status fixed. Similarly, the exp(ß₂) represents the odds of a safety-net center receiving a health equity score of A over the odds of a non-safety-net center receiving a health equity score of A holding ABA status, for-profit status, and Burn and Reconstructive Centers of America status fixed. The exponentiation of the ß₃ coefficient describes the odds ratio for receiving an A rating holding ABA, safety-net, and Burn and Reconstructive Centers of America statuses fixed and the exp(ß₄₎ coefficient is the odds ratio for Burn and Reconstructive Centers of America centers receiving a health equity rating of A, fixing ABA, for-profit, and safety-net statuses fixed. Statistical analyses were performed using SAS statistical software version 9.4 (SAS Institute). P-values of <.05 were considered statistically significant.

RESULTS

There were a total of 131 burn centers as of February 2022 (Table 1). Over half of all burn centers were verified by the ABA. About 13% were listed under Burn and Reconstructive Centers of America. About 21.1% were designated as safety-net centers; and 17.1% were designated as for-profit centers. Overall, 27.6% of burn centers had a rating of A for their health equity score, 27.6% were rated B, 41.5% were rated C, and 3.3% were rated D. Regarding location, 12.2% of all facilities were in the Eastern Great Lakes Region, 12.2% were in the Midwest, 23.7% were in the Northeast, 31.3% were in the Southern region, and 20.6% were in the Western region of the United States (Table 1).

Table 1.

Characteristics of Burn Centers Shown in (% Yes)

	Burn centers overall N = 131
American Burn Association	53.9
Missing	0.1
Burn and Reconstructive Center of America	13.0
Missing	<0.1
Safety-net center	21.1
Missing	<0.1
For-profit center	17.1
Missing	<0.1
Health equity scores
A	27.6
B	27.6
C	41.5
D	3.3
Missing	<0.1
Region
Eastern Great Lakes	12.2
Midwest	12.2
Northeast	23.7
Southern	31.3
Western	20.6
Missing	<0.1

Figure 1 shows the percentage of for-profit and of safety-net centers by state. Most states had an equal proportion of for-profit and safety-net centers. Figure 2 demonstrates the percentage of for-profit and safety-net centers by region. Burn centers in the Southern United States had greater proportions of for-profit centers compared to safety-net centers. The Western region had the greatest proportion of safety-net centers to for-profit centers. Figures 3 and 4 show the distribution of burn centers in the United States by funding status.

Figure 1.

Percent of For-Profit and Safety-Net Centers Shown by State. The Horizontal-Axis of This Figure Shows the Percentage of Burn Centers Classified as Safety-Net Centers and the Vertical-Axis Is the Percentage of Burn Centers Classified as For-Profit Centers. Each Dot Represents a State or Multiple States, If They Share the Same Proportion of Safety-Net, and For-Profit Burn Centers. States That Appear with Hollow Dots Have a Higher Proportion of Safety-Net to For-Profit Burn Centers, States with “X”s Have a Higher Proportion of For-Profit to Safety-Net Burn Centers, and States in Black on the y = x Slope Line Have Equal Proportions of Safety-Net and For-Profit Centers.

Figure 2.

Percent of For-Profit and Safety-Net Centers Shown by Region. The Horizontal-Axis of This Figure Shows the Percentage of Burn Centers Classified as Safety-Net Centers and the Vertical-Axis Is the Percentage of Burn Centers Classified as For-Profit Centers. Each Dot Represents a Region of the United States. Regions That Appear with Hollow Dot Have a Higher Proportion of Safety-Net to For-Profit Burn Centers and Regions in “X” Have a Higher Proportion of For-Profit to Safety-Net Burn Centers.

Figure 3.

For-Profit and Not-For-Profit Burn Centers in the United States. Centers Appearing as X Are Designated For-Profit Centers, Whereas Open Dots Are Not-for-Profit Centers.

Figure 4.

Safety-Net and Non-Safety-Net Burn Centers in the United States. Centers Appearing as Open Dots Are Designated Safety-Net Centers, Whereas Xs Are Not-Safety-Net Centers.

Table 2 provides the number and percentage of centers receiving health equity scores A–D by ABA verification, Burn and Reconstructive Centers of America, for-profit, and safety-net status and their crude associations. Only safety-net status was statistically significantly associated with receiving a health equity score rating of A (P < .001). In total, 34 centers received A ratings: 19 centers were ABA verified, 4 were Burn and Reconstructive Centers of America centers, 3 were for-profit centers, and 19 were safety-net centers. There were 34 centers with B ratings, 17 had ABA verification, 4 were Burn and Reconstructive Centers of America centers, 8 were for-profit, and 6 were safety-net centers. In total, 51 centers had C ratings, 25 were ABA verified, 9 were Burn and Reconstructive Centers of America centers, 10 were for-profit, and there was 1 safety-net center. Of the 4 centers with D ratings, all were ABA verified, and none were Burn and Reconstructive Centers of America centers, for-profit, or safety-net centers.

Table 2.

Health Equity Scores by Burn Center Facility Verification, Safety-Net, and Profit Status

	Health equity score
Civic score	A n = 34(%)	B n = 34(%)	C n = 51(%)	D n = 4(%)	P-value
ABA verified	19 (55.9)	17 (51.5)	25 (49.0)	4( 100.0)	.3
Burn and Reconstructive Centers of America	4 (11.8)	4 (11.8)	9 (17.7)	0 (0.0)	.8
For-profit	3 (8.8)	8 (23.5)	10 (19.6)	0 (0.0)	.3
Safety-net	19 (55.9)	6 (17.7)	1 (2.0)	0 (0.0)	<.001

Table 3 conveys the crude and adjusted odds ratio between ABA status and health equity score. The adjusted model included Burn and Reconstructive Centers of America status, for-profit status, and safety-net status. There was no statistical significance for crude or adjusted ratio. Table 4 examines the association between Burn and Reconstructive Centers of America centers and health equity score. The adjusted model included ABA status, for-profit status, and safety-net status, and neither the crude nor the adjusted ratio were statistically significant. Table 5 shows the association between for-profit centers and health equity scores. Interestingly, initially in the crude analysis, the odds ratio was 3.7 with a P-value of .3, indicating no statistical significance between for-profit centers and health equity scores. However, in the adjusted model that included Burn and Reconstructive Centers of America status, ABA status, and safety-net status, the odds ratio was 0.2 with a P-value of .04. This indicates that when holding Burn and Reconstructive Centers of America status, ABA status, and safety-net status as fixed variables, there is an 80% decrease in the odds of having a health equity rating of A with for-profit centers.

Table 3.

Crude and Adjusted Ordinal Logistic Regression Evaluating ABA Verification as Predictor of Equity Score

	ABA Verified n = 122		Crude OR (P-value)	ORa(P-value)
	No n = 57 (%)	Yes n = 65 (%)	4.0 (P = .3)	0.9 (P = .7)
Equity score
A	26.3	29.2
B	28.1	26.2
C	45.6	38.5
D	0.0	6.2

^aAdjusted for Burn and Reconstruction Centers of America status, for-profit status, and safety-net status.

Table 4.

Crude and Adjusted Ordinal Logistic Regression Evaluating Burn and Reconstructive Centers of America Status as Predictor of Equity Score

	Burn and Reconstructive Centers of America n = 123		Crude OR (P-value)	ORa(P-value)
	No n = 106 (%)	Yes n = 17 (%)	1.5 (P = .8)	2.7 (P = .2)
Equity score
A	28.3	23.5
B	28.3	23.5
C	39.6	52.9
D	3.8	0.0

^aAdjusted for American Burn Association status, for-profit status, and safety-net status.

Table 5.

Crude and Adjusted Ordinal Logistic Regression Evaluating For-Profit Status as Predictor of Equity Score

	For-profit center n = 123		Crude OR (P-value)	ORa(P-value)
	No n = 102 (%)	Yes n = 21 (%)	3.7 (P = .3)	0.2 (P = .04)
Equity score
A	30.4	14.3
B	25.5	38.1
C	40.2	47.6
D	3.9	0.0

^aAdjusted for Burn and Reconstruction Centers of America status, American Burn Association status, and safety-net status.

Table 6 additionally shows that in both the crude and adjusted associations, where the adjusted model includes Burn and Reconstructive Centers of America status, for-profit status, and ABA status, the odds of receiving a health equity score of A are significantly increased for safety-net centers compared to non-safety-net centers (crude OR = 37.2 (P < .001); adjusted OR = 21.8 (P < .001)).

Table 6.

Crude and Adjusted Ordinal Logistic Regression Evaluating Safety-Net Status as Predictor of Equity Score

	Safety-net center n = 123		Crude OR (P-value)	ORa(P-value)
	No n = 97 (%)	Yes n = 26 (%)	37.2 (P < .001)	21.8 (P < .001)
Equity score
A	15.5	73.1
B	28.9	23.1
C	51.6	3.9
D	4.1	0.0

^aAdjusted for Burn and Reconstruction Centers of America status, for-profit status, and American Burn Association status.

DISCUSSION

To our knowledge, this is the first investigation in the United States evaluating the effects of funding status on health equity ratings of facilities with burn centers. Specifically, facilities that were designated as safety-net achieved significantly higher scores than non-safety-net facilities. In addition, facilities that had for-profit designation scored significantly worse. These data expose the variation in health equity delivered by facilities with burn centers and question how the burn community should address these gaps.

Profit status and safety-net status are separate means of categorizing facilities, and 4 permutations exist; safety-net is not to imply nonprofit. Profit status is the most objective marker, given this designation is related to organizational tax structure, and is made publicly available. Burn center funding is complicated, and facilities must maintain positive finances to remain open, and continue providing burn care. It may be unfair to tout nonprofit hospitals as achieving higher equity care when these facilities receive supplemental funding and tax exemptions from governmental sources (e.g., city, county, or state) to balance otherwise negative budgets.²³ Burn centers that are for-profit systems may wish to care for disadvantaged Medicaid patients, but they chose to limit this payer to avoid accumulating deficits which threaten the existence of the burn center. Nonprofit hospitals that are also safety-net centers struggle with finances which has been amplified by national policies aimed at improving healthcare value such as bundled payment models.²⁴ These programs have adversely affected safety-net facilities that operate on lower margins and care for high volumes of lower-income, minority patients. While none of the value-based payment models have been directed at burn centers, the tenuous funding status at safety-net hospitals may make non-safety-net systems reluctant to care for more low-income burn patients. However, recent evidence challenges this paradigm.²⁵ The financial benefit of tax exemptions for nonprofit, safety-net hospitals may exceed the lost revenue from Medicaid for some facilities. This seemingly yields financial benefit to being a nonprofit organization and challenges the underlying assumptions about the differences in profit status.

In terms of the regionalization of burn care relative to funding status, there were many regions in the United States, as demonstrated in Figure 1, that provide burn care only through nonprofit, safety-net hospitals. The Pacific Northwest is such an example. In this region, it does not matter whether a patient is unemployed with Medicaid or wealthy with commercial insurance; they receive burn care from the same center, and the overall equity of healthcare delivered at that hospital was high. Conversely, in Florida, multiple burn centers exist within close proximity of each other with varying for-profit and safety-net status. Each center had varying equity scores, which suggests this region may have tiers of burn care delivery whereby low-income patients receive care at safety-net hospitals while commercially insured patients receive care at non-safety-net, for-profit centers.

Burn and Reconstructive Centers of America is a for-profit Limited Liability Company that works with hospital networks to provide high-quality burn care. We specifically investigated the relationship between Burn and Reconstructive Centers of America and equity scores, given the unique organizational structure for multi-institution burn care across the United States. There was no relationship between Burn and Reconstructive Centers of America and equity scores. This suggests that while this organization is for-profit, it functions within hospitals that achieved average or better health equity scores than national means. Furthermore, this discussion does not intend to shame for-profit centers; instead, we intend to encourage these centers to consider ways of providing equitable burn care, which may portend caring for more Medicaid and underinsured patients and engaging in community efforts focused on improving burn-related health for historically marginalized populations.

Importantly, burn center verification status was not associated with health equity scores, which likely speaks to the absence of health equity information in the ABA verification process. In its current iteration, there are no criteria that require burn centers to disclose data related to the care of burn patients by race, ethnicity, payer, or socioeconomic status. Particularly, evaluating these factors as they relate to the local and regional communities would allow centers to evaluate their relative delivery of high equity healthcare. For example, a burn center may serve a metropolitan area with a high proportion of poverty and Medicaid inhabitants, yet the dominant patient population served in the center may be commercially insured and middle class. Certainly, other explanations of demographic mismatch should be considered prior to assuming a center is excluding lower paying patients; however, data disclosure and transparency is the first step in evaluating this issue. One potential action stemming from our results is a requirement for burn centers to disclosure equity related outcomes in the Burn Center Verification Pre-Review Questionnaire (PRQ). Currently, the PRQ does not ask questions that stratify outcomes by race/ethnicity or socioeconomic status. Furthermore, the PRQ does not evaluate the demographics of patients treated at a burn center in light of surrounding community. Though burn centers are required to engage in prevention and recovery activities in the local community, there is currently no requirement to engage in activities specifically addressing equity gaps. Future verification could require at least one health equity focused project per cycle.

On a national level, improving health equity is a complex and multi-faceted process. Nundy et al. describe the history of improving healthcare beginning at first with the triple aim of improving healthcare outcomes, maximizing patient experience, and minimalizing healthcare costs.^26,27 Soon after, mediating healthcare provider burnout was added to this framework, and finally the fifth goal is improving health equity.^26,28,29 While some of the former aims allude to health equity, without an independent recognition of health equity as a distinct pillar for healthcare improvement, the former aims can inadvertently exaggerate healthcare disparities.^26,29,30 The first step in achieving health equity is identifying disparities and generating interventions to minimize these disparities.²⁶

Dzau et al. bring forth another important premise in healthcare improvement: “There is no quality without equity, and there is no equity without quality.”³¹ Historically, when we have failed to improve quality and equity in union, we cannot improve healthcare deliverables. For example, in the early 2000s, many efforts were made to improve the quality of care received to reduce heart disease, hypertension, stroke, and breast cancer, however, the beneficiaries of these healthcare delivery changes were disproportionately white. Moreover, the disparity between the mortality rates for these conditions increased between White and Black patients.^29,32 A combination of data demonstrating healthcare disparities, governance ensuring health equity in conjunction with high healthcare quality, and health equity making up organization valuation are a proposed solution to improving health equity for all.³¹ When deciding how to measure health equity, Nundy et al. urge the consideration of factors that transcend social determinants of health, and look into “primary measures of health equity, such as measures of underlying causes of inequities (e.g., racism, discrimination, mistrust, food insecurity, housing instability).”²⁶

Limitations

Our study is limited by the health equity instrument created by the Lown Institute. Other investigations have published using the Lown Institute’s data which speaks to the greater acceptance of this organization as a reliable reporter of health equity rating.^19–22 There are currently no standardized guidelines on how to measure health equity, and the Lown Institute is both forward-thinking and novel in their approach to this problem. The scoring system explicitly uses outcomes related to community benefit/charity, inclusivity by race/ethnicity, and payer. Thus, it is not entirely surprising that safety-net hospitals—which care for a large portion of Medicaid patients—score higher when payer equity is considered in the scoring. This does not undermine the premise or implications for this investigation, and instead further illuminates the wide variation in patient demographics treated by U.S. burn centers. For example, in the greater Los Angeles Metropolitan Area, there are multiple burn centers that span the health equity chasm from for-profit centers catering to patients with wealthier payers and less racial/ethnic diversity to safety-net hospitals that treat patients with Medicaid payer which also are more likely to be Black and Hispanic. Future investigations should focus on burn specific equity measures including access, acute treatment outcomes, and longer horizon outcomes. This process will require multiple stakeholders to engage in burn-specific equity measure generation.

Our investigation assumes that the health equity rating of hospitals also represents the burn centers housed within these facilities. This may not be true for some institutions where the burn center achieves health equity outcomes that are distinct from its parent facility. Future investigations could establish metrics unique to burn center and investigate patient encounters in the context of burn patients only.

CONCLUSION

Hospital funding status and safety-net designation were associated with health equity scores for facilities with burn centers across the United States. Facilities that were designated as safety-net or nonprofit had significantly higher health equity ratings compared to non-safety-net and for-profit centers. These trends were significant after adjusting for available covariates. The burn community could consider creating burn-specific equity measures which would allow for additional investigation into systems level drivers of high and low equity burn care. In addition, the American Burn Association may consider incorporating equity measure reporting in burn center verification.

Author Contributions: Nada Rizk (Conceptualization [equal], Formal analysis [lead], Investigation [equal], Methodology [equal], Writing – original draft [lead], Writing – review & editing [supporting]), Danielle Rochlin (Conceptualization [equal], Investigation [equal], Writing – original draft [supporting]), Clifford Sheckter (Conceptualization [lead], Formal analysis [supporting], Methodology [equal], Supervision [lead], Writing – original draft [equal], Writing – review & editing [lead])

Funding: A portion of this research was funded with a grant from the Center for Translation Science Advancement (CTSA) award number KL2TR003143. The contents of this manuscript do not necessarily represent the policy of the NIH, CTSA, or Federal Government.

Conflict of interest statement: The authors report no conflicts of interest related to this manuscript.