{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T22:51:06Z","timestamp":1792623066045,"version":"4.5.0"},"reference-count":34,"publisher":"American Medical Association (AMA)","issue":"7","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"<jats:sec id=\"ab-zoi250684-4\"><jats:title>Importance<\/jats:title><jats:p>The lack of universally accepted definitions for safety net hospitals (SNHs) has made it difficult to effectively design policies to support these hospitals and the populations they serve.<\/jats:p><\/jats:sec><jats:sec id=\"ab-zoi250684-5\"><jats:title>Objective<\/jats:title><jats:p>To evaluate the overlap, variation, and consistency across different definitions for SNH status.<\/jats:p><\/jats:sec><jats:sec id=\"ab-zoi250684-6\"><jats:title>Design, Setting, and Participants<\/jats:title><jats:p>This retrospective cohort study used a hospital year\u2013level dataset on short-term acute care US hospitals from 2014 to 2022. Hospital-level and area-level measures were used to define SNHs. Hospital characteristics under each definition, overlap across definitions, and stability of SNH samples produced by each definition from were described. Data analyses were performed from August 2024 to June 2025.<\/jats:p><\/jats:sec><jats:sec id=\"ab-zoi250684-7\"><jats:title>Exposure<\/jats:title><jats:p>Nine hospital-level and 4 area-level SNH definitions.<\/jats:p><\/jats:sec><jats:sec id=\"ab-zoi250684-8\"><jats:title>Main Outcomes and Measures<\/jats:title><jats:p>Hospital characteristics under each definition, overlap across definitions, and stability of SNH samples over time. Hospital-level definitions included Medicare Disproportionate Share Hospital (DSH) index, Medicare inpatient day share, dual-eligible or low-income subsidy (DLIS) inpatient day share, Medicaid inpatient day share, Medicare Safety-Net Index, teaching status, public ownership, uncompensated care share, and operating margins. Area-level measures included Area Deprivation Index, Social Vulnerability index, proportion Hispanic population, and proportion Black population. Safety net status was assigned based on quartiles defined nationally (or within a state for Medicaid-specific definitions). For a subset of measures, this quartile-based approach was compared between the absolute number of inpatient days attributed to each patient group and the relative number (or share) of inpatient days.<\/jats:p><\/jats:sec><jats:sec id=\"ab-zoi250684-9\"><jats:title>Results<\/jats:title><jats:p>Among 4531 short-term acute care hospitals, between 992 (21.9%) and 1326 (29.3%) were SNHs in 2022, depending on definition. SNHs defined based on the absolute level of inpatient days or absolute level of DLIS populations were often large (51% [242 of 476] or 67% [537 of 801]) and were not often rural (9% [45 of 476] or 2% [17 of 801]). Meanwhile, SNHs defined based on relative level of Medicaid inpatient days or relative level of DLIS patients were more often small (63% [298 of 476] and 82% [660 of 801]) and rural (48% [228 of 476] and 69% [555 of 801]) hospitals. The largest overlap across definitions was between a hospital\u2019s Medicaid inpatient day share and Medicare DSH index (55% overlap [808 of 1466 hospitals]), which tended to represent large, teaching hospitals. Public ownership, teaching status, and Medicare DSH index produced the most stable definitions of SNHs over time from 2014 to 2022, with 83% (862 of 1043), 74% (1000 of 1354), and 60% (809 of 1358) of similar hospitals, respectively, meeting safety net criteria. The least stable definitions were based on low operating margins, high uncompensated care share, and high DLIS day share, with only 15% (263 of 1796), 20% (362 of 1823), and 25% (436 of 1725) of similar hospitals, respectively, meeting safety net criteria in 2014, 2018, and 2022.<\/jats:p><\/jats:sec><jats:sec id=\"ab-zoi250684-10\"><jats:title>Conclusions and Relevance<\/jats:title><jats:p>In this cohort study of US hospitals, different SNH definitions produced different samples, and candidate measures had variable overlap and stability over time. These findings highlight the trade-offs when considering different options to define SNHs.<\/jats:p><\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2025.23923","type":"journal-article","created":{"date-parts":[[2025,7,30]],"date-time":"2025-07-30T15:31:11Z","timestamp":1753889471000},"page":"e2523923","source":"Crossref","is-referenced-by-count":10,"title":["Variation, Overlap, and Stability in Defining Safety Net Hospitals"],"prefix":"10.1001","volume":"8","author":[{"given":"Paula","family":"Chatterjee","sequence":"first","affiliation":[{"name":"Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia"},{"name":"Department of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania"},{"name":"Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joshua M.","family":"Liao","sequence":"additional","affiliation":[{"name":"Division of General Internal Medicine, University of Texas Southwestern Medical Center, Dallas"},{"name":"Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kano","family":"Amagai","sequence":"additional","affiliation":[{"name":"Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yueming","family":"Zhao","sequence":"additional","affiliation":[{"name":"Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Torrey","family":"Shirk","sequence":"additional","affiliation":[{"name":"Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amol S.","family":"Navathe","sequence":"additional","affiliation":[{"name":"Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia"},{"name":"Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia"},{"name":"Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2025,7,30]]},"reference":[{"issue":"27","key":"zoi250684r2","doi-asserted-by":"publisher","first-page":"2593","DOI":"10.1056\/NEJMp2030228","article-title":"Essential but undefined: reimagining how policymakers identify safety-net hospitals.","volume":"383","author":"Chatterjee","year":"2020","journal-title":"N Engl J Med"},{"issue":"1","key":"zoi250684r3","doi-asserted-by":"publisher","first-page":"525","DOI":"10.1146\/annurev-publhealth-071823-121237","article-title":"Saving the health care safety net: progress and opportunities.","volume":"46","author":"Chatterjee","year":"2025","journal-title":"Annu Rev Public Health"},{"issue":"12","key":"zoi250684r4","doi-asserted-by":"publisher","first-page":"1781","DOI":"10.1377\/hlthaff.2022.00153","article-title":"Variation and changes in the targeting of Medicaid disproportionate share hospital payments.","volume":"41","author":"Chatterjee","year":"2022","journal-title":"Health Aff (Millwood)"},{"issue":"12","key":"zoi250684r5","doi-asserted-by":"publisher","DOI":"10.1001\/jamahealthforum.2022.4873","article-title":"Trends in ransomware attacks on US hospitals, clinics, and other health care delivery organizations, 2016-2021.","volume":"3","author":"Neprash","year":"2022","journal-title":"JAMA Health Forum"},{"issue":"10","key":"zoi250684r7","doi-asserted-by":"publisher","first-page":"1000","DOI":"10.1001\/jama.2020.14978","article-title":"Allocation of COVID-19 relief funding to disproportionately Black counties.","volume":"324","author":"Kakani","year":"2020","journal-title":"JAMA"},{"issue":"1","key":"zoi250684r9","doi-asserted-by":"publisher","first-page":"298","DOI":"10.1089\/heq.2021.0076","article-title":"Evaluating how safety-net hospitals are identified: systematic review and recommendations.","volume":"6","author":"Powell","year":"2022","journal-title":"Health Equity"},{"issue":"9","key":"zoi250684r10","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2023.32392","article-title":"Variance of US hospital characteristics by safety-net definition.","volume":"6","author":"McNeill","year":"2023","journal-title":"JAMA Netw Open"},{"issue":"8","key":"zoi250684r11","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2019.8577","article-title":"Comparison of 3 safety-net hospital definitions and association with hospital characteristics.","volume":"2","author":"Popescu","year":"2019","journal-title":"JAMA Netw Open"},{"issue":"4","key":"zoi250684r12","doi-asserted-by":"publisher","first-page":"363","DOI":"10.1177\/0020731420937632","article-title":"Inequality set in concrete: physical resources available for care at hospitals serving people of color and other U.S. hospitals.","volume":"50","author":"Himmelstein","year":"2020","journal-title":"Int J Health Serv"},{"issue":"1","key":"zoi250684r19","doi-asserted-by":"publisher","first-page":"278","DOI":"10.1186\/s12913-021-06292-9","article-title":"Defining safety net hospitals in the health services research literature: a systematic review and critical appraisal.","volume":"21","author":"Hefner","year":"2021","journal-title":"BMC Health Serv Res"},{"issue":"11","key":"zoi250684r27","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2022.40328","article-title":"Structural racial disparities in the allocation of disproportionate share hospital payments.","volume":"5","author":"Schpero","year":"2022","journal-title":"JAMA Netw Open"},{"issue":"10","key":"zoi250684r28","doi-asserted-by":"publisher","first-page":"432","DOI":"10.37765\/ajmc.2021.88761","article-title":"340B Drug pricing program and hospital provision of uncompensated care.","volume":"27","author":"Desai","year":"2021","journal-title":"Am J Manag Care"},{"issue":"2","key":"zoi250684r29","doi-asserted-by":"publisher","first-page":"157","DOI":"10.1111\/1475-6773.13278","article-title":"Relationship between initiation of 340B participation and hospital safety-net engagement.","volume":"55","author":"Nikpay","year":"2020","journal-title":"Health Serv Res"},{"issue":"6","key":"zoi250684r30","doi-asserted-by":"publisher","first-page":"942","DOI":"10.1377\/hlthaff.2019.01545","article-title":"Varying trends in the financial viability of US rural hospitals, 2011-17.","volume":"39","author":"Bai","year":"2020","journal-title":"Health Aff (Millwood)"},{"issue":"4","key":"zoi250684r31","doi-asserted-by":"publisher","first-page":"498","DOI":"10.1377\/hlthaff.2022.01191","article-title":"Hospital survival in rural markets: closures, mergers, and profitability.","volume":"42","author":"Carroll","year":"2023","journal-title":"Health Aff (Millwood)"},{"issue":"1","key":"zoi250684r32","doi-asserted-by":"publisher","DOI":"10.1017\/cts.2024.517","article-title":"Measuring concordance and discordance between selected individual characteristics and corresponding neighborhood-level social determinants of health.","volume":"8","author":"Ngai","year":"2024","journal-title":"J Clin Transl Sci"},{"issue":"4","key":"zoi250684r33","doi-asserted-by":"publisher","DOI":"10.1111\/1475-6773.14312","article-title":"Performance of health care service area definitions for capturing variation in inpatient care and social determinants of health.","volume":"59","author":"Crook","year":"2024","journal-title":"Health Serv Res"},{"key":"zoi250684r1","unstructured":"Institute of Medicine Committee on the Changing Market, Managed Care, and the Future Viability of Safety Net Providers. America\u2019s Health Care Safety Net: Intact but Endangered. National Academies Press; 2000. Accessed June 22, 2020. https:\/\/www.nap.edu\/download\/9612#"},{"key":"zoi250684r6","unstructured":"NOAA National Centers for Environmental Information. U.S. Billion-dollar weather and climate disasters, 1980-present (NCEI Accession 0209268). 2020. Accessed May 6, 2025. https:\/\/www.ncei.noaa.gov\/access\/metadata\/landing-page\/bin\/iso?id=gov.noaa.nodc:0209268"},{"key":"zoi250684r8","unstructured":"Cassidy, Hassan release policy framework on Medicare site-neutral reform to lower health care costs. U.S. Senator Bill Cassidy. November 1, 2024. Accessed December 6, 2024. https:\/\/www.cassidy.senate.gov\/newsroom\/press-releases\/cassidy-hassan-release-policy-framework-on-medicare-site-neutral-reform-to-lower-health-care-costs\/"},{"key":"zoi250684r13","unstructured":"RAND Hospital Data. Web-based tool. RAND Corporation. 2018. Accessed September 1, 2023. https:\/\/www.rand.org\/pubs\/tools\/TL303.html"},{"key":"zoi250684r14","unstructured":"Chapter 3: Supporting safety-net providers (June 2022 report). MedPAC. Accessed May 29, 2024. https:\/\/www.medpac.gov\/document\/http-www-medpac-gov-docs-default-source-default-document-library-jun21_ch3_medpac_report_to_congress_sec-pdf-copy\/"},{"key":"zoi250684r15","unstructured":"United States Census Bureau. American Community Survey (ACS). Accessed November 10, 2020. https:\/\/www.census.gov\/programs-surveys\/acs"},{"key":"zoi250684r16","unstructured":"Hill? L, Artiga? S, Published? AD. Health coverage by race and ethnicity, 2010-2022. KFF. January 11, 2024. Accessed December 6, 2024. https:\/\/www.kff.org\/racial-equity-and-health-policy\/issue-brief\/health-coverage-by-race-and-ethnicity\/"},{"key":"zoi250684r17","unstructured":"Centers for Medicare & Medicaid Services. Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) model. February 24, 2022. Accessed December 6, 2024. https:\/\/www.cms.gov\/newsroom\/fact-sheets\/accountable-care-organization-aco-realizing-equity-access-and-community-health-reach-model"},{"key":"zoi250684r18","unstructured":"Centers for Disease Control and Prevention. Innovative uses of SVI during COVID-19. Place and health\u2014Geospatial Research, Analysis, and Services Program (GRASP). September 12, 2024. Accessed December 10, 2024. https:\/\/www.atsdr.cdc.gov\/place-health\/php\/covid19response\/innovative-uses-of-svi-during-covid-19.html"},{"key":"zoi250684r20","unstructured":"To amend title XVIII of the Social Security Act to establish a definition of essential health system in statute, H.R.7397, 118th Congress (2023-2024). Accessed December 6, 2024. https:\/\/www.congress.gov\/bill\/118th-congress\/house-bill\/7397\/text"},{"key":"zoi250684r21","unstructured":"America\u2019s Essential Hospitals. Define essential health systems in federal law. December 4, 2024. Accessed December 6, 2024. https:\/\/essentialhospitals.org\/define-essential-health-systems-in-federal-law"},{"key":"zoi250684r22","unstructured":"The White House. Executive Order on advancing racial equity and support for underserved communities through the federal government. January 21, 2021. Accessed June 20, 2024. https:\/\/bidenwhitehouse.archives.gov\/equity"},{"key":"zoi250684r23","unstructured":"Blue Cross Blue Shield Association. Creating a more equitable health system. April 2, 2024. Accessed December 6, 2024. https:\/\/www.bcbs.com\/news-and-insights\/article\/creating-a-more-equitable-system-for-the-health-of-america"},{"key":"zoi250684r24","unstructured":"HCAI. Distressed hospital loan program. Accessed October 2, 2023. https:\/\/hcai.ca.gov\/construction-finance\/distressed-hospital-loan-program\/"},{"key":"zoi250684r25","unstructured":"NY State Department of Health. Hospital Vital Access Provider Assurance Program (Hospital VAPAP). Accessed September 26, 2023. https:\/\/www.health.ny.gov\/facilities\/hospital\/vapap\/"},{"key":"zoi250684r26","unstructured":"MACPAC, Annual Report to Congress. Chapter 3: annual analysis of Medicaid disproportionate share hospital allotments to states. March 2024. Accessed September 11, 2024. https:\/\/www.macpac.gov\/wp-content\/uploads\/2024\/03\/Chapter-3-Annual-Analysis-of-Medicaid-Disproportionate-Share-Hospital-Allotments-to-States.pdf"},{"key":"zoi250684r34","doi-asserted-by":"crossref","unstructured":"Duggan? M, Gupta? A, Jackson? E, Templeton? ZS. The impact of privatization: evidence from the hospital sector. National Bureau of Economic Research working paper 30824. January 2023. Accessed May 29, 2024. https:\/\/www.nber.org\/system\/files\/working_papers\/w30824\/w30824.pdf","DOI":"10.3386\/w30824"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2836923\/chatterjee_2025_oi_250684_1753200007.61979.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,7,30]],"date-time":"2025-07-30T15:31:15Z","timestamp":1753889475000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2836923"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7,30]]},"references-count":34,"journal-issue":{"issue":"7","published-print":{"date-parts":[[2025,7,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2025.23923","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,7,30]]}}}