M. McHugh, R. Kang, and R. Hasnain-Wynia, "Understanding the Safety Net: Inpatient Quality of Care Varies Based on How One Defines Safety-Net Hospitals," Medical Care Research and Review, published online April 27, 2009.
Access to the full article is available at: http://mcr.sagepub.com/cgi/content/abstract/1077558709334895v1
The quality of care at safety-net hospitals—which serve many poor, publicly insured, and uninsured patients—varies depending on the criteria used to identify such hospitals, this study finds. Using three different, commonly used classification methods, the researchers came up with three very different sets of results. Public or teaching hospitals had lower performance scores on four "process of care" measures than did private, nonteaching hospitals, but results were mixed for safety-net hospitals identified by the level of uncompensated care they provide.
Several recent studies suggest that safety-net hospitals, particularly those with a large Medicaid caseload, provide lower-quality care and are slower to improve over time than non–safety-net hospitals. But the absence of a common definition for safety-net hospitals presents a challenge to monitoring quality and improving outcomes at hospitals that serve vulnerable patients. This study compared the performance scores of hospitals classified as safety-net providers based on three different criteria: providing a high volume of uncompensated care, having a high percentage of Medicaid-insured patients, or being a public or teaching hospital.
The study's findings are consistent with previous research showing that hospitals with a large Medicaid caseload perform worse than hospitals that do not, highlighting the need for further investigation of the quality of care provided to Medicaid beneficiaries. But the findings also point to the importance of "carefully considering the criteria used to identify safety-net hospitals," say the authors, who add that researchers should clearly state their methods for identifying safety-net hospitals and describe the implications of those methods. A standardized definition for a safety-net hospital might include a combination of the three approaches used in this study—for example, a hospital that meets a threshold for Medicaid and uninsured patients served and that has certain facility characteristics.
The authors analyzed responses from 4,554 participants in the 2006 American Hospital Association Survey. Safety-net hospitals were identified by their volume of uncompensated care, their Medicaid caseload, or their facility status (public or teaching hospital). Safety-net hospitals with a high ratio of uncompensated care to total expenses were designated "high-burden" providers, while "high-market" providers provided more uncompensated care relative to other hospitals. "Core" safety-net hospitals met both criteria for uncompensated care. The authors used 2008 Hospital Quality Alliance Scores to measure performance on four process-of-care measures, including treatment of acute myocardial infarction, heart failure, and pneumonia, and prevention of surgical infection.
It is too simplistic to conclude that safety-net providers perform worse or better than non–safety-net providers. Findings vary depending on how safety-net hospitals are defined.