Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California.
Rand Corporation, Los Angeles, California.
JAMA Netw Open. 2019 Aug 2;2(8):e198577. doi: 10.1001/jamanetworkopen.2019.8577.
No consensus exists on how to define safety-net hospitals (SNHs) for research or policy decision-making. Identifying which types of hospitals are classified as SNHs under different definitions is key to assessing policies that affect SNH funding.
To examine characteristics of SNHs as classified under 3 common definitions.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional analysis includes noncritical-access hospitals in the Healthcare Cost and Utilization Project State Inpatient Databases from 47 US states for fiscal year 2015, linked to the Centers for Medicare & Medicaid Services Hospital Cost Reports and to the American Hospital Association Annual Survey. Data were analyzed from March 1 through September 30, 2018.
Hospital characteristics including organizational characteristics, scope of services provided, and financial attributes.
Definitions of SNH based on Medicaid and Medicare Supplemental Security Income inpatient days historically used to determine Medicare Disproportionate Share Hospital (DSH) payments; Medicaid and uninsured caseload; and uncompensated care costs. For each measure, SNHs were defined as those within the top quartile for each state.
The 2066 hospitals in this study were distributed across the Northeast (340 [16.5%]), Midwest (587 [28.4%]), South (790 [38.2%]), and West (349 [16.9%]). Concordance between definitions was low; 269 hospitals (13.0%) or fewer were identified as SNHs under any 2 definitions. Uncompensated care captured smaller (200 of 523 [38.2%]) and more rural (65 of 523 [12.4%]) SNHs, whereas DSH index and Medicaid and uncompensated caseload identified SNHs that were larger (264 of 518 [51.0%] and 158 of 487 [32.4%], respectively) and teaching facilities (337 of 518 [65.1%] and 229 of 487 [47.0%], respectively) that provided more essential services than non-SNHs. Uncompensated care also distinguished remarkable financial differences between SNHs and non-SNHs. Under the uncompensated care definition, median (interquartile range [IQR]) bad debt ($27.1 [$15.5-$44.3] vs $12.8 [$6.7-$21.6] per $1000 of operating expenses; P < .001) and charity care ($19.9 [$9.3-$34.1] vs $9.1 [$4.0-$18.7] per $1000 of operating expenses) were twice as high and median (IQR) unreimbursed costs ($32.6 [$12.4-$55.4] vs $23.6 [$9.0-$42.7] per $1000 of operating expenses; P < .001) were 38% higher for SNHs than for non-SNHs. Safety-net hospitals defined by uncompensated care burden had lower median (IQR) total (4.7% [0%-9.9%] vs 5.8% [1.2%-11.2%]; P = .003) and operating (0.3% [-8.0% to 7.2%] vs 2.3% [-3.9% to 8.9%]; P < .001) margins than their non-SNH counterparts, whereas differences between SNH and non-SNH profit margins generally were not statistically significant under the other 2 definitions.
Different SNH definitions identify hospitals with different characteristics and financial conditions. The new DSH formula, which accounts for uncompensated care, may lead to redistributed payments across hospitals. Our results may inform which types of hospitals will experience funding changes as DSH payment policies evolve.
目前在研究或政策决策中，对于如何定义安全网医院（SNH）还没有达成共识。确定在不同定义下哪些类型的医院被归类为 SNH，是评估影响 SNH 资金政策的关键。
研究 3 种常见定义下 SNH 的特征。
设计、设置和参与者：本横断面分析包括来自美国 47 个州的医疗保健成本和利用项目州住院数据库中 2015 财年的非关键通道医院，与医疗保险和医疗补助服务中心医院成本报告以及美国医院协会年度调查相关联。数据于 2018 年 3 月 1 日至 9 月 30 日进行分析。
包括组织特征、提供的服务范围和财务属性在内的医院特征。
基于 Medicaid 和 Medicare 补充性安全收入住院天数的 SNH 定义，这些定义曾用于确定 Medicare 不成比例份额医院（DSH）支付； Medicaid 和未参保病例数；以及无偿护理费用。对于每种衡量标准，将各州的前四分之一作为 SNH。
本研究中的 2066 家医院分布在东北部（340 家[16.5%]）、中西部（587 家[28.4%]）、南部（790 家[38.2%]）和西部（349 家[16.9%]）。定义之间的一致性较低；在任何 2 个定义下，只有 269 家（13.0%）或更少的医院被归类为 SNH。无偿护理费用覆盖的 SNH 较少（523 家的 200 家[38.2%]）且更多位于农村地区（523 家的 65 家[12.4%]），而 DSH 指数、 Medicaid 和未参保病例数确定的 SNH 更大（518 家的 264 家[51.0%]和 487 家的 158 家[32.4%]），并且是教学医院（518 家的 337 家[65.1%]和 487 家的 229 家[47.0%]），提供的基本服务比非 SNH 更多。无偿护理费用还区分了 SNH 和非 SNH 之间显著的财务差异。在无偿护理费用定义下，中位数（四分位距[IQR]）的呆账（$27.1 [$15.5-$44.3] 比每 1000 美元运营费用的 $12.8 [$6.7-$21.6]；P <.001）和慈善护理（$19.9 [$9.3-$34.1] 比每 1000 美元运营费用的 $9.1 [$4.0-$18.7]；P <.001）是后者的两倍，中位数（IQR）的未偿费用（$32.6 [$12.4-$55.4] 比每 1000 美元运营费用的 $23.6 [$9.0-$42.7]；P <.001）则高 38%。与非 SNH 相比，由无偿护理负担定义的 SNH 的中位数（IQR）总（4.7% [0%-9.9%] 比 5.8% [1.2%-11.2%]；P =.003）和运营（0.3% [-8.0% 至 7.2%] 比 2.3% [-3.9% 至 8.9%]；P <.001）利润率更低，而在其他 2 种定义下，SNH 和非 SNH 利润率之间的差异通常不具有统计学意义。
不同的 SNH 定义确定了具有不同特征和财务状况的医院。新的 DSH 公式考虑了无偿护理费用，可能会导致医院之间的支付重新分配。我们的研究结果可以为 DSH 支付政策演变时，哪些类型的医院会经历资金变化提供信息。
