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Editor's Note
July 2, 2021

Identifying Safety Net Hospitals Consistently

Author Affiliations
  • 1Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
JAMA Health Forum. 2021;2(7):e211240. doi:10.1001/jamahealthforum.2021.1240

Social determinants of health have emerged as an important factor in health care access, delivery, and outcomes. Social determinants of health influence the cost and delivery of high-quality care in numerous ways. Patients with disadvantaged socioeconomic status (SES) and the hospitals that care for them face social risks that shape not only patient need for care but also the costs of delivering high-quality care. These hospitals are often described as safety net hospitals.

However, the precise characteristics that define a safety net hospital remain a matter of some debate. Safety net hospitals that care for a disproportionate number of patients from disadvantaged social backgrounds and communities are more likely to have worse outcomes, such as a 30-day readmission rate.1 Consequently, some of these hospitals face higher financial penalties from certain reimbursement policies, such the Medicare Hospital Readmission Reduction Program.2

To address some of these concerns, the Improving Medicare Post-acute Care Transformation Act of 20143 stipulated the need to conduct studies to understand the association of patients’ SES with quality measures and resource use. In response, the US Department of Health and Human Services embarked on these studies,4,5 and the National Academies of Sciences, Engineering, and Medicine produced an advisory report to guide this work.6,7 More recently, the 21st Century Cures Act8 specified that financial penalties be stratified by the proportion of patients with dual eligibility for Medicare and Medicaid, which is one of the recommended measures of social risk.

However, whether the proportion of patients with dual eligibility for Medicare and Medicaid is a sufficient marker of social risk to identify safety net hospitals is unclear. The study by Matty et al9 in JAMA Network Forum sought to advance this discussion. The authors assessed 7 measures of social risk to examine how consistently they identified the same hospitals. These risk factors included individual measures such as African American race or Medicaid coverage and zip code residence measures such as income below the US poverty level; educational attainment less than high school graduation; unemployment; living in a crowded household; and Agency for Healthcare Quality index for SES score. The authors assessed the proportion of hospitals caring for disadvantaged patients across 18 publicly reported Centers for Medicare & Medicaid Services hospital outcomes and payment measures. Specifically, the study sought to determine whether the aforementioned social risk factors would consistently identify hospitals as safety net hospitals. Instead, they found very limited consistency in identifying hospitals that care for disproportionate numbers of disadvantaged patients. However, the analysis did not fully assess how these risk factors are associated with the dual-eligibility criterion or whether the addition of some social risk factors the authors identified would contribute to a more optimal definition of a safety net hospital.

The association between social risk and hospitals’ quality-of-care performance is premised on the notion that hospitals serving high proportions of socially disadvantaged patients are often underresourced. Matty et al9 did not directly assess the association between hospital resources and patient-centered metrics of hospital performance.

This new study underscores that there is no single best definition of social risk that can be used to identify all hospitals serving disadvantaged populations. Rather, each definition of social risk identifies a different group of hospitals. The optimal social risk factor may depend on the social context and the policy purpose (eg, research vs payment). However, a combination of social risk factors may perform better than any single factor in identifying most of the hospitals that care for high proportions of disadvantaged patients.

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Article Information

Published: July 2, 2021. doi:10.1001/jamahealthforum.2021.1240

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Ibrahim S. JAMA Health Forum.

Corresponding Author: Said Ibrahim, MD, MPH, MBA, Department of Population Health Sciences, Weill Cornell Medicine, 402 E 67th St, Floor 2, Room LA 215, New York, NY 10060 (sai2009@med.cornell.edu).

Conflict of Interest Disclosures: None reported.

Boccuti  C, Casillas  G. Aiming for fewer hospital U-turns: the Medicare Hospital Readmission Reduction Program. March 10, 2017. Accessed April 29, 2021. https://www.kff.org/medicare/issue-brief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/
Gilman  M, Adams  EK, Hockenberry  JM, Milstein  AS, Wilson  IB, Becker  ER.  Safety-net hospitals more likely than other hospitals to fare poorly under Medicare’s value-based purchasing.   Health Aff (Millwood). 2015;34(3):398-405. doi:10.1377/hlthaff.2014.1059 PubMedGoogle ScholarCrossref
HR4994. 113th Congress (2013-2014). Improving Medicare Post Acute Care Transformation Actt of 2014. September 16, 2014. Pub L No. 113–185.
Office of the Assistant Secretary for Planning and Evaluation.  Report to Congress: Social Risk Factors and Performance Under Medicare’s Value-Based Purchasing Programs. US Department of Health and Human Services; 2016.
Joynt  KE, De Lew  N, Sheingold  SH, Conway  PH, Goodrich  K, Epstein  AM.  Should Medicare value-based purchasing take social risk into account?   N Engl J Med. 2017;376(6):510-513. doi:10.1056/NEJMp1616278 PubMedGoogle ScholarCrossref
Committee on Accounting for Socioeconomic Status in Medicare Payment Programs; Board on Population Health and Public Health Practice; Board on Health Care Services; Institute of Medicine; National Academies of Sciences, Engineering, and Medicine.  Accounting for Social Risk Factors in Medicare Payment. National Academies Press; 2017.
Buntin  MB, Ayanian  JZ.  Social risk factors and equity in Medicare payment.   N Engl J Med. 2017;376(6):507-510. doi:10.1056/NEJMp1700081 PubMedGoogle ScholarCrossref
21st Century Cures Act. Pub L No. 114-255, 130 Stat 1033.
Matty  R, Heckmann  R, George  E,  et al.  Identification of hospitals that care for a high proportion of patients with social risk factors.   JAMA Health Forum. Published online July 2, 2021. doi:10.1001/jamahealthforum.2021.1323Google Scholar
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