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Strengthening the Health Care Safety Net

Monitoring Providers & Populations


Helen Burstin, M.D., Director, Center for Primary Care Research, Agency for Healthcare Research and Quality (AHRQ), Rockville, MD.

Dr. Burstin described the critical need to improve the Nation's capacity and ability to monitor the changing structure and financial stability of the health care safety net. She also discussed the development of a more unified strategy for collecting and analyzing relevant indicators.

In its March 2000 report, titled America's Safety Net: Intact But Endangered, the Institute of Medicine (IOM) makes an important recommendation regarding the need to improve the Nation's capacity to monitor the status of safety net providers (SNPs) and populations. The report calls for the development of "a comprehensive, coordinated tracking and reporting capability...[to] promote public accountability, as well as a more coordinated approach to data collection, technical assistance, and the application and dissemination of best practices."

In response to this recommendation, AHRQ has joined forces with the Health Resources and Services Administration (HRSA) and the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in a new effort to monitor the status of the health care safety net.

Dr. Burstin explained the goal of the initiative is "to design a data collection, analysis, and dissemination system that can provide information on an ongoing basis on the status of both traditional and non-traditional SNPs and the historically underserved populations in which they provide care."

The specific aims of the monitoring are to track changes in the status and viability of SNPs to:

  • Assess the impact of health status on vulnerable populations.
  • Create early-warning systems to identify potential viability problems.
  • Identify sentinel measures and related data sources.

Dr. Burstin sought input from workshop participants to identify what kinds of information about SNPs and populations they need as policymakers and program administrators. Suggestions included:

  • Numbers and demographics of the uninsured.
  • Differences in health status and access in rural versus urban areas.
  • Costs of providing uncompensated care and identifying different types of safety net providers.

A complete list of participant suggestions follows, organized by topic:

The Uninsured

  • How large is the uninsured population?
  • How do we understand the actual number of uninsured? Who are they? Where do they live?
  • How many of the uninsured work and how do they break down in income level?
  • In counties surrounding our urban/suburban areas, what are the number of uninsured using our safety net?
  • Are there more accurate demographics on the insured, such as the number of children?
  • What are the most pressing medical needs of the uninsured?
  • What type of care do the uninsured really want—comprehensive versus urgent?
  • How many uninsured people live in County X?
  • Are health care-seeking behaviors different for an uninsured population, and what is the impact on the safety net?
  • Why are there uninsured, given our generous coverage policies?
  • We need accurate, real-time data.


  • How much does State or County X spend on indigent care?
  • What is the average cost of taking care of an indigent patient over the course of a full year?
  • How much uncompensated care, in dollars, is provided by the SNPs by category?
  • How much do we spend for care that could have been prevented with good ambulatory care?
  • What is the cost of not providing primary care? What is the cost of not providing mental health and substance abuse care?
  • We need to do public finance analysis—are taxpayers in high uninsured States actually paying higher taxes?

Rural Use of Safety Nets

  • What is the number of people from rural areas that use urban safety nets?
  • What is the difference in health status and access between rural and urban patients?

Safety Net Providers

  • What are the numbers and categories of immigrants being served in the community health centers (CHCs)?
  • Which providers are culturally competent and/or willing to serve?
  • How is continuity of care determined across SNPs?
  • How do I know if my SNP is financially sound?
  • Are there early indicators of when a CHC is heading for financial trouble?
  • What kind of outreach and followup is provided by SNPs?

Service Delivery

  • Who has been seeing uninsured patients? What was done to these patients?
  • What is the number of people that use multiple sites for care, and is that care being duplicated?

Behavior of Those Using Safety Net

  • What is the number of people who access care when sick, then stop using care; and the number of new people that sign up for care? (Measure prevention versus use of service when only very sick.)
  • Are migration data available that track certain populations who move to cities that offer better care for certain diseases (acquired immunodeficiency syndrome, hepatitis C)?
  • What is the elasticity of copayments for this population?
  • Why would low-income people want insurance?
    1. Protection, why?
    2. Value of insurance.
    3. What is it that these populations want?
    4. Do they want comprehensive care? (New Mexico used a household survey to answer this question).
    5. Why do they need insurance? They have emergency rooms, care in urban areas, care offered but not taken.
  • How do we know whether persons using one SNP are using others?
  • We need information on how people chose to or are made to move between one status and another.


  • What is the status of the public health system as support for these populations? (Centers for Disease Control and Prevention National Performance Standards).
  • How can we track movement of low-income persons between status of being uninsured, Medicaid-covered, or employer-covered?
  • Are there better data on undocumented cases, such as how many, where concentrated, and impact on SNPs?
  • Why does this county/State with high insurance rates still have poor health-status indicators?
  • What is the purpose of safety net monitoring system? Fiscal capacity for safety net; monitor Community Access Program (CAP) projects.
  • Need clear and uniform definitions for "uncompensated care," "charity care," and "bad debt."


Choose sentinel populations (sick, functionally disabled, immigrant, etc.) that are "bellwethers" of endangered health due to poor care access and/or quality:

  • Choose same sentinel populations for Quality Report.
  • Use external sampling of existing surveys when necessary.
  • Analyze by these populations with existing data.
  • Offer oversamples at State/community cost for subnational measurement.

Broadly sample primary care providers (including dentists) and selected specialists to measure extent and estimated aggregate impact of the broadly disseminated uncompensated/sliding scale provided. That way:

  • This is a large pool of care.
  • Some policy directors focus on coaxing more equitable participation from the bulk of providers. How would we know if it happens?
  • Distinguishing who gets care as a "continuing patient in hard times" from those without similar access as an important intervention targeting issue.

It's common to have questions on "usual source of care" and "from where?" These tend to assume that continuity of provider is everyone's value. Consider adding something on:

  • "How often do you see the same provider?" If the answer is "Rarely," "Is this a problem?"
  • Unique patient identifier to link data sets; use neutral third party to link.
  • Need to follow up data sets with interviews.
  • Have multiple ways of reporting visits/encounters. We need to create a uniform way to link and integrate. Help States with integrating surveys, samples for local analysis.
  • A minimum data set? Try optional modules rather than minimum; monitor sentinel populations.

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