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Tools for Monitoring the Health Care Safety Net

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By Robin M. Weinick, Ph.D. and John Billings, J.D.


What is the Safety Net?
Overview of This Book
Where to Find More Information


In 2000, the Institute of Medicine (IOM) released a report describing the health care safety net in the United States as "intact but endangered." In particular, the report emphasized the precarious financial situation of many institutions that provide care to Medicaid, uninsured, and other vulnerable patients; the changing financial, economic, and social environment in which these institutions operate; and the highly localized, "patchwork" structure of the safety net. One of the five key recommendations in the report concerns the need for data systems and measures:

"The committee recommends that concerted efforts be directed to improving this nation's capacity and ability to monitor the changing structure, capacity, and financial stability of the safety net to meet the health care needs of the uninsured and other vulnerable populations" (Institute of Medicine, 2000).

In response to this recommendation, the Agency for Healthcare Research and Quality (AHRQ) and the Health Resources and Services Administration (HRSA) are leading a joint safety net monitoring initiative. This is the third product of the initiative, entitled Monitoring the Health Care Safety Net—Book 3: Tools for Monitoring the Health Care Safety Net. It offers strategies and concrete tools for assessing local health care safety nets. With topics ranging from estimating the size of local uninsured populations to using administrative data and presenting information to policymakers, the chapters can assist State and local health officials, planners, and analysts in assessing the capacity and viability of their existing safety net providers as well as in understanding the characteristics and health outcomes for the populations served.

The other two books from this initiative brought together 118 measures, largely from 1999, at the city, county, metropolitan, and State levels. Monitoring the Health Care Safety Net—Book 1: A Data Book for Metropolitan Areas presented data from 90 metropolitan areas in 30 States and the District of Columbia, including 354 counties and 171 cities. Monitoring the Health Care Safety Net—Book 2: A Data Book for States and Counties showed data from all 1,818 counties in these States, including both metropolitan and non-metropolitan counties. A Web-based Safety Net Profile Tool ( provides electronic access to the data and can be used to generate easy-to-use reports on the geographic areas covered in the two data books.

What Is the Safety Net?

Considerable debate has been generated concerning the definition of the health care "safety net." The IOM defines the safety net as:

"Those providers that organize and deliver a significant level of health care and other health-related services to uninsured, Medicaid, and other vulnerable patients" (Institute of Medicine, 2000).

Much of the discussion centers on which providers in a community are "safety net" providers, and which ones are not. The IOM also recognized the concept of "core safety net providers:"

"These providers have two distinguishing characteristics: (1) by legal mandate or explicitly adopted mission they maintain an "open door," offering access to services to patients regardless of their ability to pay; and (2) a substantial share of their patient mix is uninsured, Medicaid, and other vulnerable patients" (Institute of Medicine, 2000).

Core providers identified by the IOM include a variety of health centers (e.g., Community Health Centers, Migrant Health Centers, the Health Care for the Homeless Program, School-Based Health Centers, and the Public Health Housing Program), community-based clinics, public hospitals, and many teaching hospitals as well. A substantial amount of safety net care is provided in hospital emergency departments, which, as a condition of participation in the Federal Medicare program, are required to provide medical screening exams and stabilizing treatment to all patients, regardless of their ability to pay. In addition, the IOM recognized that a considerable, but largely unquantified amount of health care for safety net populations is provided in private physicians offices.

For this volume, we have accepted the IOM safety net definition and have focused largely on the community since safety nets are often defined by political boundaries. Data in the companion volumes about resources, context, and outcomes of safety net are organized by municipality and county, with data also provided at the metropolitan area level to recognize the regional nature of health services. No effort has been made to designate particular providers as "safety net" providers, but rather the focus is on the needs and services for vulnerable populations in geographic areas.

Overview of This Book

Part 1. Gathering Information About People and Providers

The first section describes a variety of methods for obtaining the data needed to understand, monitor, and improve the status of the safety net and the populations it serves. In Estimating the Size of the Uninsured and Other Vulnerable Populations in a Local Area, Lynn Blewett and Timothy Beebe address a crucial issue: how to estimate the size of the uninsured population in a local area. Without this information, it is difficult to estimate the need for safety net services, since the uninsured comprise a large part of the population using these services. Blewett and Beebe describe three primary methods for estimating the size of the uninsured population: conducting a survey, using proxy measures, and developing model-based approaches. The advantages and disadvantages of each technique are reviewed and discussed.

In Local Data Collection Strategies for Safety Net Assessment, Joel Cantor provides details on conducting surveys correctly to create information that is both relevant and accurate. This chapter is intended to provide realistic guidance to community organizations interested in conducting health care access surveys. Cantor also describes ways in which surveys can bring local stakeholders together in a common understanding.

Having focused on obtaining information about populations, Part 1 then shifts to an emphasis on the financial health of safety net providers. In Assessing the Financial Health of Hospitals, Jack Needleman focuses on approaches and measures that can help in evaluating the extent to which hospitals are functioning as financially viable business concerns. These include assessing the balance between revenues and expenses and analyzing the adequacy of resources for delivering services in the short and long term. This chapter provides the information necessary to understand the financial impact on safety net hospitals of providing substantial amounts of uncompensated care.

The section closes with a chapter from Timothy Clouse, Gilbert Silva, and Robert Gilliam addressing methods for determining the financial health of outpatient safety net providers. Assessing Safety Net Provider Financial Health: A Simple Measurement Tool presents a tool that uses a few common financial measures to identify providers at risk of developing financial problems. Clouse, Silva, and Gilliam present a method for comparing an outpatient safety net provider's financial situation with that of a representative sample of similar providers and for rating its performance relative to them. An interactive version of their tool is available at

Part 2. Understanding and Using the Information

The second section discusses ways in which data can be used to understand the status of the safety net and potentially improve its performance. In Using Administrative Data To Monitor Access, Identify Disparities, and Assess Performance of the Safety Net, John Billings describes the uses of administrative data for analyzing the safety net, with a focus on vital statistics records, hospital discharge data, and emergency department data. He explains the strengths and weaknesses of these data and how they have been used to focus attention on access to care, disparities, and local safety net performance. The chapter also describes two tools for data analysis, which are available electronically at

Mapping Tools for Monitoring the Safety Net provides an overview of the use of Geographic Information Systems (GIS), which permit the combination of complex population, health care services, and clinical data into maps that can help inform decisionmaking regarding care for safety net populations. In this chapter, Robert Phillips, Andrew Bazemore, and Thomas Miyoshi offer examples of their work with community health centers and describe the basic data elements needed from all safety net providers to create more comprehensive service maps. They also show maps of population data that demonstrate potential safety net needs, discuss sources of these data, and illustrate how to combine these data with safety net maps.

Walter "Pete" Bailey presents a case study of South Carolina's data in Integrated State Data Systems. This chapter describes the unique analyses of the safety net that are possible with a data system that includes information from a wide variety of health and human services programs. It explains the power of integrated data and provides practical advice to States and local communities about principles for building such a system.

Part 2 closes with Presenting Information to Decisionmakers: A Guide for Policy Analysts in which Lawrence Lewin and Marion Ein Lewin describe some of the tools and lessons learned from numerous consulting engagements. They emphasize the presentation of data to key decisionmakers in ways they can use to evaluate potential policy changes. In addition, the authors present a framework for policy analysis and provide several examples of its application.

Part 3. Understanding Special Circumstances: The Safety Net in Rural Areas

The safety net functions differently in rural areas than in urban ones and must address a separate set of specialized issues. In Rural Health Care Safety Nets, David Hartley and John Gale provide an overview of the issues and programs unique to rural safety nets.

Where to Find More Information

Book 3 offers strategies and concrete tools for assessing local health care safety nets. The tools supplement the data in the two previous books from the Safety Net Monitoring Initiative, which provide data on factors related to the health care safety net, including demand, financial support, structure and health system context, and community context. By providing these additional methods to help in understanding and monitoring local health care safety nets, these tools can be used to help improve the performance of the safety net and access to care for the populations it serves.

Book 1. Data for Metropolitan Areas presents data from 90 metropolitan areas in 30 States and the District of Columbia, including 354 counties and 171 cities. Additional data are in Book 2. Data for States and Counties. Its tables focus on information for every county in 30 States and the District of Columbia. All data in these two volumes are available on the CD included with Book 1 and in a variety of formats at

Also online is the Safety Net Profile Tool, which offers easy access to all the data in the Safety Net Monitoring Initiative. The Profile Tool will guide the user step-by-step in obtaining statistics and can be used to generate reports that compare multiple measures for one or more geographic areas.

Print versions of all three books are available free:

  • By calling the AHRQ Publications Clearinghouse at (800) 358-9295.
  • By mail from the AHRQ Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907-8547.
  • By sending an E-mail to

Please request the following publication numbers:

Book Publication No.
1. A Data Book for Metropolitan Areas AHRQ 03-0025
2. A Data Book for States and Counties AHRQ 03-0026
3. Tools for Monitoring the Health Care Safety Net AHRQ 03-0027

Current as of November 2003

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