Department of Pediatrics, Boston Medical Center, Boston, Massachusetts.
Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.
JAMA Netw Open. 2023 Apr 3;6(4):e238785. doi: 10.1001/jamanetworkopen.2023.8785.
Safety net hospitals (SNH) provide many community services. The cost of providing these services is unknown.
To determine what safety net criteria are associated with differences in hospital operating margin.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study of US acute care hospitals from 2017 to 2019 included eligible hospitals identified from US Centers for Medicare & Medicaid Services Cost Reports.
Five domains of SNH: undercompensated care measured using the Disproportionate Share Hospital index, uncompensated care, essential community services, neighborhood disadvantage, and sole community hospital and critical access hospital status. Each was categorized as a quintile or binary response. Covariates included hospital ownership, size, teaching status, census region, urbanicity, and wage index.
Operating margin and its association with each safety net criterion was determined using linear regression adjusting for all safety net criteria and covariates.
A total of 4219 hospitals were analyzed, of which 3329 hospitals (78.9%) satisfied at least 1 safety net criterion; 23 hospitals (0.5%) met 4 or all 5 criteria. Among safety net criteria, the highest quintile of undercompensated care (-6.2 percentage point difference compared with lowest quintile; 95% CI, -8.2 to -4.2 percentage points), uncompensated care (-3.4 percentage points; 95% CI, -5.1 to -1.6 percentage points), and neighborhood disadvantage (-3.9 percentage points; 95% CI, -5.7 to -2.1 percentage points) were each associated with a lower operating margin. No association with operating margin was found between critical access or sole community hospital status (0.9 percentage points; 95% CI, -0.8 to 2.7 percentage points) or the highest vs lowest quintile of essential services (0.8 percentage points; 95% CI, -1.2 to 2.7 percentage points). Among essential services, burn, inpatient psychiatry, and primary care services were associated with lower operating margin, while others were either not associated or showed positive association. Fall-off in operating margin by level of uncompensated care was most severe in the highest percentiles of uncompensated care, with the most marked declines among those with the lowest operating margin.
In this cross-sectional study of SNH, hospitals in the highest quintiles of undercompensated care, uncompensated care, and neighborhood disadvantage were more financially vulnerable than those not in the top quintile, especially when they met numerous of these criteria. Ensuring targeting of financial support to these hospitals could improve their financial stability.
安全网医院（SNH）提供许多社区服务。提供这些服务的成本尚不清楚。
确定哪些安全网标准与医院运营利润率的差异有关。
设计、地点和参与者：这项对 2017 年至 2019 年美国急症护理医院的横断面研究包括从美国医疗保险和医疗补助服务成本报告中确定的符合条件的医院。
SNH 的五个领域：使用不成比例的份额医院指数衡量的补偿不足的护理、未补偿的护理、基本社区服务、邻里劣势以及唯一的社区医院和关键接入医院的地位。每个领域都被归类为五分位数或二进制响应。协变量包括医院所有权、规模、教学地位、人口普查区域、城市性和工资指数。
使用线性回归确定运营利润率及其与每项安全网标准的关联，该回归调整了所有安全网标准和协变量。
共分析了 4219 家医院，其中 3329 家（78.9%）符合至少 1 项安全网标准；23 家（0.5%）符合所有 5 项标准。在安全网标准中，补偿不足的最高五分位数（与最低五分位数相差 6.2 个百分点；95%CI，-8.2 至-4.2 个百分点）、未补偿的护理（3.4 个百分点；95%CI，-5.1 至-1.6 个百分点）和邻里劣势（3.9 个百分点；95%CI，-5.7 至-2.1 个百分点）均与较低的运营利润率相关。关键接入或唯一社区医院的地位（0.9 个百分点；95%CI，-0.8 至 2.7 个百分点）或最高与最低五分位数的基本服务（0.8 个百分点；95%CI，-1.2 至 2.7 个百分点）与运营利润率之间无关联。在基本服务中，烧伤、住院精神病学和初级保健服务与较低的运营利润率相关，而其他服务则要么没有关联，要么表现出正相关。随着未补偿护理水平的提高，运营利润率的下降幅度最大，在运营利润率最低的人群中降幅最为明显。
在这项对 SNH 的横断面研究中，补偿不足、未补偿护理和邻里劣势最高五分位数的医院比不在前五分位数的医院财务上更脆弱，尤其是当他们符合这些标准中的许多标准时。确保将财政支持集中在这些医院上，可以提高它们的财务稳定性。
