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From Health Affairs

The Good, the Bad and the Possible for the US Safety Net Examined in Health Affairs' August 2012 Issue


Articles Explore How Health Reform Could Affect Tenuous Network of Care



Bethesda, MD -- Research and analysis in the August issue of Health Affairs, supported by a grant from the Blue Shield of California Foundation, focuses on the state of the safety net for uninsured and low-income Americans in the context of key provisions in the Affordable Care Act. The authors examine a range of issues, including how prepared safety-net hospitals and clinics are for the impending influx of new patients through health reform; whether they will succeed in attracting newly insured patients who will have the ability to access other providers; and existing problems in emergency care that warrant new solutions.

Additional articles in this issue address the causes of--and potential solutions for--large disparities in life expectancy based on race and education; the potential for savings if Medicare covered certain diabetes care for young patients; and the implications of the recent Supreme Court decision on Medicaid expansion.

Sara Rosenbaum, Harold and Jane Hirsh Professor of Health Law and Policy at the George Washington University School of Public Health and Health Services, and colleagues present five case studies on the practice of "patient dumping" in apparent violation of the 25-year-old Emergency Medical Treatment and Labor Act (EMTALA). A seminal element of US health policy whose guarantees were the subject of significant discussion in the recent Supreme Court decision over the Affordable Care Act, EMTALA requires hospitals to screen and stabilize any patient who comes to an emergency department, regardless of the patient's ability to pay. Yet substantial evidence shows that hospitals continue to deny emergency care outright or "dump" certain patients on other facilities, largely affecting the most vulnerable patients and the critical health care safety-net providers that serve them.

The authors attribute EMTALA violations to complexities of the law, regulations that further limit its provisions, weak federal enforcement, and oversight and inconsistent judicial interpretations of the law. Using the experiences of Denver Health, a leading public safety-net hospital, the authors--who include Philip Mehler and Joel Hirsh and have experienced EMTALA's limitations firsthand--point to a series of clear or potential EMTALA violations. They also make recommendations to help improve oversight and enforcement.

"We don't know the full extent of EMTALA violations because they aren't properly reported and tracked, but we do know that there are serious problems with how the law has been implemented," said Rosenbaum. "Denver is not a unique community, and in our view, the experiences of Denver Health probably are emblematic of safety-net hospitals throughout the country. Improving this watershed legislation will entail clearer standards, a rapid reporting system, and enforcements that are sufficiently robust to reduce patient risk."

Nancy Kane, professor of management and associate dean for educational programs at the Harvard School of Public Health, and colleagues analyze how governance, competition, and financial performance interplay at 150 safety-net hospitals, with an unexpected finding--many publicly owned safety-net hospitals have maintained surprising profitability, due largely to state and local government support. This refutes the assumption that public ownership and control of hospitals results in worse financial performance. Of the subset of hospitals interviewed, five of the six publicly owned sites received supplemental Medicaid payments worth 3 to 12 percent of all revenues in 2007, versus 1 to 2 percent of revenue at the private sites, and four of those six received additional local government subsidies of between 25 to 35 percent of total revenues. The authors suggest that with these government payments in hand, these hospitals haven't had to innovate in management, cost control, and other areas--leaving them vulnerable in a slower economy and more demanding legislative environment.

Interviews revealed that safety-net hospitals' deficits were offset by local tax revenues and Medicaid supplemental payments. The authors also found that the political composition and connections of hospital leadership had a direct effect on the level of fiscal control and that private, nonprofit safety-net hospitals had a higher level of oversight.

"These safety-net hospitals face significant reductions in Medicaid disproportionate share payments along with recession-induced reductions in local tax subsidies," said Kane. "It's a whole new ballgame, and they're going to have to adapt and compete, or they won't survive."

    Related articles include:

  • Study shows quality is equal at safety-net and non-safety-net hospitals. Joseph Ross, Yale University School of Medicine, finds that despite unique financial challenges, safety-net hospital performance related to outcomes for acute myocardial infarction, heart failure, and pneumonia were effectively identical to non-safety-net hospitals in urban metro areas.

  • Hospitals serving minorities more likely to be overcrowded. Renee Yuen-Jan Hsia, University of California, San Francisco, finds that hospitals serving large minority populations are more likely to be overcrowded, and more often divert ambulances to other facilities, delaying treatment. These findings raise questions about whether measures should be taken to alleviate these hospitals that have undue burdens on their resources, as well as regulations on diversion, to combat disparities in access to timely emergency care.

  • Safety-net hospitals prepare for operating under the Affordable Care Act. Teresa Coughlin, Urban Institute, and colleagues examine how five safety-net hospitals have begun making organizational and systems changes in preparation for health reform, with health information technology and systems integration capacity key factors in readiness.

  • How community health centers can increase access to subspecialty care. Katherine Neuhausen, Robert Wood Johnson Foundation Clinical Scholar, University of California, Los Angeles, describes six models for how community health centers can increase access to subspecialty care. The Integrated Systems Model establishes "medical neighborhoods" and appears to provide the most comprehensive and cohesive access to subspecialty care.

  • What California reveals for integrating care for the newly insured. Nadereh Pourat, Fielding School of Public Health, University of California, Los Angeles, assesses how 10 California counties redesigned care for largely poor and uninsured populations, suggesting integrated delivery systems provide a useful approach for newly insured patients.

In another featured study, Elaine Rabin, assistant professor in the Department of Emergency Medicine at the Mount Sinai School of Medicine, and colleagues examine the systemic health care issues leading to "boarding" patients in emergency department hallways, a major cause of emergency department crowding and a source of harm to patients. In most US hospitals, both private and safety-net, patients are routinely kept waiting on stretchers or beds for hours and even days before being brought to an inpatient room. Though boarding is a widespread issue, the authors say female, black, elderly, and psychiatric patients were disproportionately subjected to this practice and that boarding is particularly common in hospitals in large urban areas.

Boarding is attributed to "patient outflow obstruction" that prevents admitted patients from being moved to an inpatient bed in a timely manner, widely viewed as within two hours. The authors say major contributing factors are hospital flow inefficiencies and saving beds for other admitted patients who often come for profitable elective procedures. The authors cite many hospitals that have implemented proven strategies to address boarding and crowding, yet fewer than half of one recent survey's respondents have implemented more than two of nine suggested measures. The authors then discuss possible financial and other reasons that boarding has not been more aggressively addressed, noting that hospital leadership involvement is key and may need to be encouraged by regulation if it does not increase voluntarily.

"Boarding is unsafe for patients, and it is happening in hospitals that serve wealthy patients as well as swamped safety-net hospitals. It's in the best interest of hospitals and patients to take boarding seriously, and hospital leadership needs to take advantage of practices we know work," said Rabin. "If public and financial pressures aren't enough to make this happen, regulation may be needed to address this widespread and dangerous phenomenon."



About Health Affairs

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print, with additional Web First papers published periodically at The full text of each Health Affairs Web First paper is available free of charge to all website visitors for a two-week period following posting, after which it switches to pay-per-view for nonsubscribers. Web First papers are supported in part by a grant from The Commonwealth Fund. You can also find the journal on Facebook and Twitter. Read daily perspectives on Health Affairs Blog. Download our podcasts, including monthly Narrative Matters essays, on iTunes. Tap into Health Affairs content with the new iPad app.