It’s rarely on a stage or in a glossy report that you first notice the framing of “winners and losers.” It’s in a waiting area with worn vinyl chairs and a shabby TV in a corner that’s playing a show during the day that nobody is watching.
While his wife stands at the check-in window, reciting their insurance ID number as if it were a spell, a man in a fleece jacket scrolls through his phone and sighs at a headline about “top hospitals.” A silent conclusion descends somewhere between the clipboard ballet and the fluorescent lighting: this system distributes trophies, and patients can typically tell if they’re holding one—or paying for it.
| Category | Details |
|---|---|
| Topic | Rankings, ratings, “winners/losers” narratives in healthcare |
| Common “Scorecards” | Hospital rankings, safety grades, insurer plan star ratings, policy “winners/losers” lists |
| Why It’s Back | Cost pressure, payment penalties/bonuses, investor narratives, consumer marketing |
| Known Problem | Major national hospital rating systems often disagree on who’s “best” |
| Patient Impact | Confusion, steering, delayed care, administrative friction, unequal access |
| Reference (authentic) | Health Affairs paper on discordant hospital ratings: https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2014.0201 |
The reason these lists are back is that, aside from those who have symptoms, practically everyone can benefit from them. They are popular with health systems because badges and awards make good donor decks, billboards, and website banners.
Because rankings can support “high-value” steering and limited networks, insurers prefer them. Because “winners” sounds like predictability, and predictability sounds like margin protection, investors like them. After years when Covid, staffing, and inflation made every quarterly call sound like a confession booth, there’s a feeling that the industry missed the reassuring simplicity of a scoreboard.
The issue is that the scorekeepers cannot agree on the rules because healthcare is not a sport. The major hospital rating systems had surprisingly little in common, according to a widely cited Health Affairs study comparing them.
No hospital was a “high performer” across all four systems, and only a small percentage of hospitals that received praise from one system also received praise from another. That may be the most truthful aspect of the rankings: they represent conflicting interpretations of what constitutes “good,” pieced together using various data sources, incentives, and blind spots. Patients don’t see methodology; they assume it follows them into the examination room because they see a gold badge next to the hospital name.
On paper, the rankings are intended to aid in decision-making. In reality, they frequently feel like patients who are already worn out are being forced to learn a second language.
A different system might grade “safety” using a different definition, U.S. News might reward complex-care reputations, and commercial rating programs can be partially funded through promotional licensing agreements. That does not imply that all rankings are corrupt. However, it does bring up a persistent question: are we focusing on quality or the most effective marketing strategy when a hospital advertises its grade?
The “winners and losers” list that is released following a bill, regulation, or budget agreement is a variant of the same habit that is prevalent in policy culture. Coverage presented a federal healthcare package in late 2024 in precisely those terms: telehealth extensions were hailed, pharmacy benefit managers were portrayed as villains, physicians were irritated by the exclusions, and patients were primarily viewed as an implied audience rather than the protagonist. The labels are suspiciously neat, as though the messy human results could be condensed into an earnings table, even though they may be directionally accurate.
Patients quickly discover where the “loser” category lurks: in appointment calendars that push specialists out by months, in prior authorization loops, and in unexpected denials that show up after the procedure has already been scheduled. While the patient experience is typically more detailed and degrading, the winners-and-losers language exacerbates this by teaching everyone to think in blocs—industry vs. government, payers vs. providers.
Which stakeholder “won” is irrelevant to a parent attempting to refill an asthma prescription. They find it bothersome that the pharmacy tech repeatedly turns the screen away and shakes her head, as though the rejection could spread.
Whether the next wave of measurement will make care easier or simply more defensible is still up in the air. Certain metrics actually put pressure on systems to lessen damage.
Others appear to encourage box-checking, pushing hospitals to maximize the quantifiable while neglecting the unquantifiable. Clinicians discuss the feeling of practicing medicine while being evaluated by non-physicians based on data that is blunt and arrives late with a hint of dread. It’s difficult to ignore how frequently “quality” turns into “billable proof that we tried” as you watch this play out.
Organizations that have enough employees to handle the bureaucracy—teams devoted to coding, compliance, appeals, contracting, and performance reporting—usually emerge as the “winners.” That does not imply that every hallway has better care.
It implies that they can make it through the game. Safety-net hospitals and complicated patients who don’t behave like clean data points are frequently the “losers,” increasing the risk of readmission and care expenses for reasons that don’t neatly fit into a dashboard. The system has a tendency to penalize complexity as though it were misbehavior, even when the goal is fairness.
The consumer layer is where rankings and the contemporary desire to buy everything come together. Similar to how people compare headphones, they also compare hospitals. It makes sense. It’s also depressing. One of the few industries where the buyer is typically afraid, the product is difficult to assess, and the bill comes as a plot twist after the fact is healthcare.
Even though the ocean beneath it is still roiling, a “winner” badge can feel like a life raft in that situation.
The most peculiar aspect is how commonplace everything has become. Winners and losers are discussed in the industry as if they were weather: unfortunate, unavoidable, and impersonal. Patients, however, do not perceive it as weather.
They perceive it as money, time, mobility, and dignity. Furthermore, it doesn’t sound cynical when someone murmurs, half-jokingly, “We know which one we are,” in a waiting area. A system that continuously publishes scorecards while the human score is being tallied elsewhere seems to be honing its pattern recognition skills.
