For the purposes of this environmental scan, we use the Institute of Medicine’s definition of safety net providers: “providers that organize and deliver a significant level of both health care and other health-related services to the uninsured, Medicaid, and other vulnerable populations,” as well as providers “who by mandate or mission offer access to care regardless of a patient’s ability to pay and whose patient population includes a substantial share of uninsured, Medicaid, and other vulnerable patients” (IOM 2000).
This definition includes most—if not all—public hospitals that are often the providers of last resort in their community by virtue of their mission, governance, services provided, and dependence on revenue from local taxes and other government subsidies. Academic medical centers also serve a major safety net function in many communities, combining their teaching function with a mission to serve vulnerable populations. In communities without public hospitals or academic medical centers, private hospitals often are the major safety net providers, either by mission (for example, religiously affiliated hospitals) or default, especially for those located in low-income urban areas. Safety net hospitals often provide services that other hospitals in the community do not offer, such as trauma, burn care, neonatal intensive care, and inpatient behavioral health. In addition, many safety net hospitals are major providers of ambulatory care services in their community. For example, the average member hospital of the National Association of Public Hospitals and Health Systems (NAPH) had a network of 20 or more ambulatory care sites, which could include on-campus clinics as well as freestanding clinics that may serve as medical homes for community residents (Zaman et al. 2012).
Most safety net hospitals—both public and private—receive subsidies from Medicaid and Medicare DSH payments because of the large amount of care they provide to uninsured people; however, because of the way that some states allocate DSH funds, the amount of DSH subsidies that hospitals receive is not always a good indicator of their commitment to uninsured and vulnerable populations (GAO 2008). Many researchers have identified safety net hospitals based on the volume of care provided to uninsured and/or Medicaid patients, although there is no specific threshold of the amount of care provided to uninsured people that clearly identifies an institution as being a safety net hospital (Gaskin and Hadley 1999). Thus, although all agree that safety net hospitals comprise a broader group than just public hospitals, there is no standard or widely agreed-upon definition that is used to identify all safety net hospitals from available data.