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Invited Commentary
Health Policy
August 7, 2019

Refining the Definition of US Safety-Net Hospitals to Improve Population Health

Author Affiliations
  • 1Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota
  • 2Hennepin Healthcare Research Institute, Minneapolis, Minnesota
JAMA Netw Open. 2019;2(8):e198562. doi:10.1001/jamanetworkopen.2019.8562

Safety-net hospitals (SNHs) in the United States provide care for individuals and families regardless of their ability to pay.1 Since 1986, SNHs have received supplemental federal compensation through Medicare Disproportionate Share Hospital (DSH) payments. These payments have historically been calculated based on the proportion of hospital days accounted for by Medicare Supplemental Security Income plus Medicaid, non-Medicare inpatient days. The Affordable Care Act (ACA) modified this definition and reduced DSH payments to offset a growing insured, low-income population.2

In JAMA Network Open, Popescu et al3 highlight the implications of modifying the definition of SNHs used by the Centers for Medicare & Medicaid Services to allocate DSH payments. The authors examined concordance among SNH definitions based on the traditional Medicare DSH index and 2 commonly used contrasting definitions of safety-net status, the proportion of inpatient stays that were uninsured or paid by Medicaid and the cost of uncompensated care. They defined SNHs as those in the top quartile of each definition and found that each definition isolated a unique group of hospitals with limited overlap. Their results demonstrate that the definition of SNH is not merely a semantic policy detail; rather, it defines the purpose of the program and could determine the financial viability of hundreds of US hospitals.

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