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Safety Net Monitoring Initiative

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Fact Sheet

The health care safety net—the Nation's system of providing health care to low-income and other vulnerable populations—was recently described as "intact but endangered." The Agency for Healthcare Research and Quality and the Health Resources and Services Administration are leading a joint initiative to monitor it.

The goal is to help local policymakers, planners, and analysts monitor the status of their local safety nets and the populations they serve. Strategies include providing baseline data and a set of tools that enable monitoring of the capacity and performance of local safety nets.

This fact sheet describes the activities of this Safety Net Monitoring Initiative.

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In 2000, the Institute of Medicine (IOM) released a report describing the health care safety net—the Nation's "system" of providing health care to low-income and other vulnerable populations—as "intact but endangered." In particular, the report emphasizes:

  • 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.
  • The highly localized, "patchwork" structure of the safety net.

One of the five key recommendations in the report is 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."1

In response, the Agency for Healthcare Research and Quality (AHRQ) and the Health Resources and Services Administration (HRSA) are leading a joint safety net monitoring initiative. An expert meeting in November 2000 provided an overview of the issues involved in establishing a monitoring system. Those attending the meeting recommended a monitoring system with four main goals:

  • Provide baseline information and an assessment of policymakers' information needs for the safety net system and its environment.
  • Establish an early warning system to alert policymakers to changes in safety net capacity and stability.
  • Provide information to policymakers about the status of safety net providers and the populations they serve that can help in designing interventions and strategies to achieve policy objectives.
  • Develop and implement a research agenda on safety net and access-related issues for low-income populations.

To accomplish these goals, there is a critical need to:

  • Develop clearer knowledge of what needs to be measured.
  • Identify data and measures that are currently available.
  • Identify opportunities and strategies to develop data capacity.
  • Assess the feasibility of monitoring these areas.

The agencies involved have agreed to a three-part strategy focusing on both safety net providers and the populations they serve:

  1. Creating two data books that describe baseline information on a wide variety of local safety nets. Select for details on measures in the data books.
  2. Developing a tool kit for State and local policymakers, planners, and analysts to assist them monitor the status of their local safety nets.
  3. Identifying the data elements that would be needed to effectively monitor the capacity and performance of local safety nets.

1. Lewin ME, Altman S, editors. America's health care safety net: intact but endangered. Committee on the Changing Market, Managed Care, and the Future Viability of Safety Net Providers. Washington, DC: National Academy Press; 2000.

What is the Health Care Safety Net?

The health care safety net consists of a wide variety of providers delivering care to low-income and other vulnerable populations, including the uninsured and those covered by Medicaid. Many of these providers have either a legal mandate or an explicit policy to provide services regardless of a patient's ability to pay.

Major safety net providers include public hospitals and community health centers as well as teaching and community hospitals, private physicians, and other providers who deliver a substantial amount of care to these populations.

Data Books for Monitoring the Safety Net

One of the challenges in monitoring the Nation's health care safety net is that safety net services are provided in a myriad of different configurations, largely at the local level. As a result, the data books include information at the county and metropolitan levels, focusing on 30 States and the District of Columbia. Together, these areas cover 75 percent of the U.S. population. The books use data from a wide variety of sources to describe the status of the safety net in 90 metropolitan areas and 1,818 counties in these States.

The books provide a broad range of measures for monitoring the status of local safety nets and the populations they serve, including:

  • Demand for Safety Net Services. Includes measures of uninsurance, poverty, disability, and AIDS.
  • Financial Support for Safety Net Services. Includes measures related to Medicaid, Disproportionate Share Hospital payments, Community Health Centers, and Uncompensated Care Pooling.
  • Safety Net Structure and Health System Context. Includes a wide range of measures describing area hospitals, the distribution of uncompensated and Medicaid discharges, characteristics of the ambulatory care system, managed care, and physician supply.
  • Community Context. Includes a wide range of measures on topics such as population size and growth, racial/ethnic distribution of the population, immigration, the economy, housing, education, and crime.
  • Outcomes and Safety Net Performance. Includes measures of preventable hospitalizations, birth outcomes, and barriers to accessing care.

There are two data books. Book 1 focuses on metropolitan areas, providing data tables as well as analytic summaries of the measures included. Book 2 provides data for all counties (urban and rural) in the 30 States examined.

Tools for Monitoring the Safety Net

Similar to the data books, which provide information on the status of the health care safety net in metropolitan areas and counties, the tool kit (Book 3) is designed to help policy analysts and planners at the State and local levels assess the performance and needs of their local safety nets.

This publication will consist of a series of papers from experts in the field covering a wide variety of topics related to monitoring the safety net, including:

  • Estimating the size of uninsured populations in local areas. This paper provides an overview of varying methodologies using secondary data and primary data collection to estimate the size of the safety net population.
  • Strategies for local data collection. This paper describes existing household-based survey instruments, how to use them, and which questions may be most helpful for studying local safety nets. It also provides an overview of the basics of developing and pretesting a questionnaire for local use and describes how to draw a sample for administering the survey.
  • Assessing safety net provider financial health. This paper presents a tool for understanding which providers are at risk of developing financial problems.
  • Using administrative data to develop performance/outcome measures. This paper describes the use of hospital discharge data, emergency department data, and vital statistics for assessing the performance of local safety nets, with a particular focus on the measurement of preventable hospitalizations. This paper covers sources of data as well as how to analyze and interpret them.
  • Mapping tools for understanding the safety net. This paper demonstrates the use of geographic information systems for understanding the needs of safety net populations.
  • Effectively presenting data to policymakers. This paper describes how to present data to policymakers in ways they can use effectively.
  • Monitoring rural safety nets. This paper provides an overview of issues specific to rural health care safety nets.
  • Best practices for State data systems. This paper provides a case study of the South Carolina integrated State data system, with a focus on what can be learned from the types of data and data linkages included in the system.

For More Information

For more information about the Safety Net Monitoring Initiative, contact:

Center for Delivery, Organization, and Markets—AHRQ
540 Gaither Road, 5th floor
Rockville, MD 20850

Or go to:

AHRQ Publication No. 03-P011
Current as of August 2003


The information on this page is archived and provided for reference purposes only.


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