1. John Billings, J.D. Robin M. Weinick, Ph.D. Agency for Healthcare Research and Quality Health Resources and Services Administration Monitoring the Health Care Safety Net

2. 2 GOALS OF INITIATIVE Begin to provide a national capacity to assess status of the safety net and access problems for vulnerable populations Help local communities: –Illustrate approaches to measuring status and performance of the local safety net –Provide bench marks for comparing local safety nets

3. 3

4. 4 MONITORING THE SAFETY NET: THE CONCEPTUAL MODEL Safety nets are largely local Health of the nation’s safety net is the sum of these local safety nets It’s important to focus on patient “outcomes” The factors that influence those outcomes are complex Need data at the local level, but safety net boundaries differ We gathered data on as many jurisdictions as possible Requires a broad range of measures to tell the story Our efforts limited to readily available data

5. 5 OPTIMAL HEALTH GENETICS ENVIRONMENT LIFESTYLE/ BEHAVIOR PERSONAL HEALTH MAINTENANCE CARE AVAILABILITY PROVIDER PERFORMANCE DISEASE/CONDITION MANAGEMENT Health Care Safety Net PERSONAL FACTORS HEALTH KNOWLEDGE PERCEPTIONS OF SYSTEM PERSONAL CHARACTERISTICS PERSONAL RESOURCES PERSONAL CIRCUMSTANCES CONTEXTUAL FACTORS HEALTH DELIVERY SYSTEM PUBLIC HEALTH SYSETM COMMUNITY ENVIRONMENT COMMUNITY INFRASTRUCTURE NEIGHBORHOOD CHARACTERISTICS CIVIC ENVIRONMENT-CIVIL CULTURE STATE/NATIONAL POLICIES COMPONENTS OF OPTIMAL HEALTH MEDIATING FACTORS MONITORING THE SAFETY NET: MORE COMPLETE MODEL

6. 6 MONITORING THE SAFETY NET: TYPES OF MEASURES Contextual factors –Demand for safety net services –Financial support for safety net services –Safety net structure and health system context –Community context Patient outcomes and safety net performance –Preventable hospitalizations –Birth outcomes –Usual source of care/reported access problems

7. 7 Figure 3-1 Percent of Population Under 200 Percent of Poverty Uninsured Metropolitan Areas 1999 Each ◊ represents a metropolitan area [Not all areas are identified] NortheastSouthMidwestWest

8. 8 Figure 3-3 Percent of Population Below Poverty and Percent Uninsured Adults Ages 18-64 Metropolitan Areas – 2000 Each “ “ represents an MSA area ▪ R 2 =.074

9. 9 Figure 4-3 Percent of Population Below 200 Percent of Poverty on Medicaid Metropolitan Areas Each ◊ represents a metropolitan area [Not all areas are identified] NortheastSouthMidwestWest

10. 10 Table 4-4 Community Health Centers and County-Level Poverty Percent of County Population Below Federal Poverty Level 2000 Percent of Counties with Community Health Centers 1999 Less than 6 percent15.9 6 percent to 9.9 percent51.7 10 percent to 20 percent77.8 More than 20 percent92.3 All Counties56.6

11. 11 Table 5-7 A Tale of Two Cities: Portland, Oregon and Newark, New Jersey, 1999 Portland, Oregon MSA Newark, New Jersey MSA HMO Market Penetration47.5%24.9% Physicians per 100,000 Persons70.4110.2 Hospital Beds per 1,000 Persons1.73.6 Emergency Department Visits per 1,000 Persons253.1390.2 Cost Shifting Index5.721.0

12. 12 Table 5-8 A Tale of Two Counties: Orange County and San Francisco, California, 1999 Orange County San Francisco City and County Percent of Admissions in Public Hospitals0.0%21.2% Not-for-Profit Hospitals61.5%78.8% Investor-Owned Hospitals38.5%0.0% Percent of Admissions in Major Teaching Hospitals0.0%51.4% Other Teaching Hospitals25.2%16.7% Non-Teaching Hospitals74.8%31.9%

13. 13 MONITORING THE SAFETY NET: TYPES OF MEASURES Population size, density and growth Age distribution Race/ethnicity, foreign-born, and indices of separation Income Unemployment Living arrangements, housing ownership and vacancy Education Crime COMMUNITY CONTEXT

14. 14 MONITORING THE SAFETY NET: TYPES OF MEASURES OUTCOMES/SAFETY NET PERFORMANCE Preventable/avoidable hospitalizations –By age Birth outcomes –Late/no prenatal care –Low birth weight births –Preterm births Survey-based access measures –Percent with no usual source of care –Percent with no MD visit in last year/last 2 years –Percent unable to get “needed care”

15. 15 Figure 7-1 Preventable/Avoidable Hospitalizations Per 1,000 Children Ages 0-17 Metropolitan Areas 1999 Each ◊ represents a metropolitan area. [Not all areas are identified.] NortheastSouthMidwestWest

16. 16 Figure 7-6 Preventable/Avoidable Hospitalizations (Children Ages 0-17) and Percent of the Population Below Poverty Cities, County Residuals, and Suburban Counties – 1999 Each “ “ represents a city/county/county “residual” area. ▪ R 2 =.341

17. 17 Figure 7-7 Preventable/Avoidable Hospitalizations (Adults Ages 40-64) and Percent of the Population Below Poverty Cities, County Residuals, and Suburban Counties – 1999 Each “ “ represents a city/county/county “residual” area. ▪ R 2 =.531

18. 18 Multivariate Results Federal and state financing of the safety net helps Greater Medicaid coverage and higher DSH payments are generally associated with lower preventable hospitalization rates and better birth outcomes Public facilities matter Larger public hospital presence associated with lower adult preventable hospitalizations and lower rates of preterm births

19. 19 Multivariate Results More providers is not always the answer More pediatricians associated with lower children’s preventable hospitalizations, but no association between adult primary care providers and preventable hospitalizations, or between more OB/GYNs and better birth outcomes Levels of personal distress are a concern Higher levels of poverty, unemployment, disability, low education, and social isolation are associated with higher levels of preventable hospitalizations and worse birth outcomes

20. 20 Data Products Two print volumes MSA (including CD) State Electronic files PDF and HTML versions of print products Excel spread sheets SAS, SAS transport, and Stata files http://www.ahrq.gov/data/safetynet Safety Net Profile Tool

21. 21

22. 22

23. 23

24. 24