Most people choose their doctor first, not their hospital. But there are times when you want to be sure the hospital your doctor uses is highly ranked, especially for the type of care you’ll be receiving.

As most of you know, I’m an orthopedic surgeon. In the field of orthopedics, there are many specialty areas and many specialty hospitals. Finding the best hospital for the specialty you need is important. You want a hospital that does a lot of the procedures you’re facing; not a place that only does that procedure once in a while. And you want a hospital that has a proven track-record of success with a low complication rate. How do you find such a hospital?

If you want to find a good car, you’ll probably check Edmunds or Kelley Blue Book. When you want to take a trip, you’ll probably check the ratings of Trip Advisor. Until recently, if you wanted to find the best hospital, many people relied upon U.S. News & World Report. After more than 30 years, U.S. News & World Report has become the most publicly visible ranking source for health care institutions.

Anthony A. Romeo, M.D. and Nikhil N. Verma, M.D., writing for Healio/Orthopedics, say this is changing. In recent years, the U.S. News rankings have been criticized by numerous leading institutions. Some top academic centers in the United States have withdrawn participation in the process with strong suggestions that the results provide artificially skewed perceptions and distorted incentives.

Romeo and Verma say the rankings are flawed and they give reasons. The first step of performing a ranking analysis is to obtain consistent data among various institutions that will comprise the source of the analysis and conclusions. The U.S. News data are largely obtained from the American Hospital Association, including patient satisfaction scores and CMS data. CMS data are limited to Medicare patients, with 86% of the patients being aged 65 years or older. Perhaps you’re looking for an ACL reconstruction or rotator cuff repair. These procedures are usually done in a younger population.

Even the Medicare age data are flawed. The most common orthopedic procedures within the Medicare population are hip and knee replacement. But strangely, these procedures are excluded from the U.S. News ranking algorithm. The outcomes and complications of these procedures are similar across the entire Medicare population, especially at the top health care institutions evaluated with U.S. News rankings.

The authors say, “Due to the limited variability, the results of the most common elective orthopedic procedures in the Medicare population are not reflected in the overall rankings. If 50% or more of the Medicare procedures being performed are removed from the analysis, along with the absence of procedures in the non-Medicare population, the analysis and subsequent ranking represent less than 10% of the overall orthopedic procedural volume, providing minimal evidence for conclusions related to overall orthopedic program quality and outcomes.”

Another flaw they point out is the use of risk-adjusted mortality as a proxy for quality. Mortality is a “worst-case” approximation of outcome. In contrast, understanding outcomes in orthopedic literature is largely determined by patient-reported outcome measures (PROM). These measure pain, function, satisfaction and quality of life – what patients really need to know about the procedures they’re having. But PROMs are not reported to CMS or any accrediting body and thus, are not available for use.

These are just a few of the flaws mentioned by the authors in this disturbing report. If you’re looking for the best hospital for orthopedics, try looking somewhere else than the U.S. News & World Report rankings.

In a recent blog post called Texans at the School Choice Showdown, I discussed the battle being waged by Texas Governor Greg Abbott to bring more school choice to Texas. In this reliable red state with Republican control of the Governor’s mansion and the legislature, you wouldn’t expect this to be a difficult hill to climb.

But Texas is so large that it has many rural counties where there are few other options for public school students. Republicans that represent these counties seem to believe that school choice doesn’t offer them anything better than the current public schools and may threaten their future.

To move the ball forward, Governor Abbott called a 30-day special session of the legislature to debate the issue. There is only one day left in the session and unless they come to an agreement, Abbott has threatened to call another 30-day session.

A breakthrough came last week when Mr. Abbott said he’d reached a deal with House Speaker Dade Phelan on a bill to establish education savings accounts, or ESAs, for families who want options outside of public schools. The universal program would be open to any K-12 student, and it would provide about $10,500 to each. That’s more generous than the $8,000 ESA package passed by the state Senate earlier in the session.

The agreement also includes billions of dollars for public education, including raises for teachers, which Mr. Abbott pledged to add to the agenda only when lawmakers reached a deal on school choice. The shrewdness of the Governor’s approach is that the political calculation ought to be simple: Voting yes means helping families who want out of public schools, while also helping public schools.

You’d think this would be a slam-dunk since it seems to benefit both charter and private schools, as well as public schools. But some of the rural Republicans have joined the Democrats in resisting ESAs. Their claim is that because their districts have few private schools, education choice doesn’t help their constituents. But ESAs could help change that, since they’d be a financial incentive for alternatives that might serve some families better than the local government school monopoly.

The Texas Tribune recently reported that the state has almost 1,200 private schools, but only 55 are in the 165 counties with 50,000 or fewer people. This sounds like an argument in favor of school choice, not against it. “If vouchers are approved to allow state money to be spent on private education,” the article says, private schools could act on their dreams of “expanding the reach of programs into relatively underserved areas, particularly in rural parts of Texas.”

The framework announced by Messrs. Abbott and Phelan is a good one, and it could be the starting point for negotiations in a renewed special session. If lawmakers still can’t come to agreement, the Governor might need to make good on plan B. Mr. Abbott has suggested he might support primary challengers to lawmakers who oppose ESAs, as Iowa Gov. Kim Reynolds successfully did in 2022. At least eight school-choice advocates have already lined up to run against GOP incumbents.

School choice benefits all children since it gives everyone the freedom to choose the best school for their needs. It frees parents to make decisions in the interest of their children, instead of the interests of the teachers unions. In Florida, where I live, school choice is growing in popularity and private schools are rapidly making plans for expansion. School choice has been called the “civil rights issue of our times” by former Secretary of State Condoleeza Rice. It’s about time that everyone got on board.

“Don’t touch Social Security or Medicare!” Every politician has been told that. They call them “the third rail of politics” because to touch them is the same as touching the third rail of a railroad track – it’s fatal. But both entitlement programs are destined for bankruptcy unless someone has the courage to change them.

President Biden and former President Trump are the leading candidates for the 2024 presidential election. Both have promised the voters they won’t touch Social Security or Medicare. Both are political cowards who don’t have the courage to change them and who aren’t willing to tell the American people the truth.

That’s not just my opinion; it’s also shared by healthcare economist John C. Goodman, writing for Forbes and for independent.org. Goodman says they’re both being irresponsible. According to the latest Social Security and Medicare Trustees reports, in the very near future the trust funds supporting these two programs will be depleted. If the president and the Congress do nothing in the interim, the law requires automatic cuts in benefits. Maybe they both just want that to happen so they don’t get the blame for making any changes.

But real leaders see problems that need solutions and make those solutions happen before the disaster happens. Goodman says, “In just eight years, nearly 78 million Medicare beneficiaries will face an automatic 11 percent payment cut in their hospital insurance benefits, and these cuts could come even sooner and strike even deeper if America is hit by a recession. In just ten years, 66 million Social Security beneficiaries will see their monthly benefit checks cut by 23 percent.”

But it gets worse. That is just the short-term problem. Looking further into the future, the Trustees reports remind us that we have made promises to millions of workers who are paying payroll taxes today, and the future cost of those promises far exceeds the expected revenues dedicated to support them. Further, the gap between future promises and future revenues keeps getting larger through time. Looking indefinitely into the future, the trustees tell us that the combined promises in both programs exceed expected revenues by $163 trillion.

It’s nearly impossible to get your head around a number like $163 trillion! That number is in current dollars and it is an unfunded liability that is almost seven times the size of today’s entire economy. Goodman says in a sound retirement system, we would have $163 trillion in the bank earning interest—so the funds would be there to pay the bills as they arise. In fact, we have no money in the bank for future expenses and there is no serious proposal to change that.

Hoover Institution economist David Henderson argues that of the two programs, Medicare is the easiest to reform. The reason? Social Security benefits come in the form of cash. Medicare benefits are services in kind. In making his argument, Henderson points to a well-regarded academic finding that Medicaid beneficiaries value enrollment in Medicaid at as little as 20 cents on the dollar. That means that if you offered the enrollees membership in Medicaid or a sum of money equal to a little more than one-fifth of the cost of Medicaid, a great many enrollees would take the money.

Is it possible that the value seniors place on Medicare is similarly much below what Medicare actually costs? If so, there would be an opportunity to spend less on medical benefits, give seniors a cash rebate and lower the taxpayers’ burden—all at the same time. A mechanism for accomplishing that would be a Health Savings Account, a device that allows younger people to make choices between medical care and other uses of money. A similar account, but with after-tax deposits and tax-free withdrawals (like a Roth IRA) for seniors would avoid the charge that the deposits are a tax dodge. But it would allow seniors to conveniently avoid unneeded care and bank the savings for other purposes.

This is one of a number of ideas proposed in Moderning Medicare, a multi-authored Johns Hopkins University publication, edited by Heritage Foundation scholar Robert Moffitt and former Heritage vice president Marie Fishpaw.

A number of authors point to the Medicare Advantage program, which already enrolls half of all beneficiaries, as the vehicle for change. In this program, seniors enroll in private plans that are similar to the employer-provided plans they had when they were in the work force. Medicare pays for a large share of the cost of the premiums.

American Enterprise Institute economist Joe Antos points out that in the Medicare Advantage program, seniors pay one premium to one plan. By contrast, in traditional Medicare they pay three premiums to three plans: one to Medicare Part B, one to Medicare Part D, and one for Medicap coverage. Antos says traditional Medicare must become more like Medicare Advantage, which saves seniors money and which allows for integrated care—such as combining medical costs and drug costs in the same plan.

In another chapter, former Medicare and Medicaid director Gail Wilensky and Johns Hopkins University School of Medicine professor Brian J. Miller argue that Medicare Advantage should be the default option for enrolling seniors. Right now, if seniors don’t elect a choice, they are automatically enrolled in traditional Medicare. Wilensky and Miller would enroll them in an MA plan instead. This idea has real merit.

In a chapter by Goodman, he argues for a number of reforms to make Medicare Advantage work better—including continuous open enrollment and the right of return to traditional Medicare. If the enrollees’ medical conditions change, they should be able to switch to a plan more appropriate for their care. If diabetes emerges, enrollees should be able to switch to a special needs plan specializing in diabetic care. If enrollees develop heart disease, they should be able to switch to a special needs plan for congestive heart failure. No one should have to wait 12 months to enroll in the plan that best meets their medical needs.

Currently, if a senior stays in an MA plan for more than a year and then choses to return to traditional Medicare there can be financial penalties. In all states, Medigap insurers are barred from discrimination on the basis of a health condition when the enrollee first becomes eligible for coverage. But a returnee from an MA plan can be “underwritten” and charged a higher premium if a health condition suggests higher medical costs. This is wrong, and it is easy to correct. Further, if people know that they can easily return to traditional Medicare when a need arises, that makes enrollment in MA plans more desirable.

(Author’s Note: For more on this issue, see my recent two-part series called Medicare Mistakes to Avoid.)