November 1997

Grant Results

SUMMARY

During 1995 and 1996, researchers at the Lewin Group, a health care and social services consulting firm based in Falls Church, Va., took a snapshot of the state of the health care safety net in four urban areas: Dallas, Los Angeles, Memphis, and New York City.

The research team also made program development recommendations to the Robert Wood Johnson Foundation (RWJF) regarding the maintenance and improvement of the health care safety net.

A similar grant was awarded to Kalkines, Arky, Zall, & Bernstein (ID# 027417) to assess the viability of the safety net in three other cities (Boston, Miami, Philadelphia) and also in New York City.

Key Findings

  • Safety-net providers delivered a wide range of services, but an integrated "net" was noticeably absent.
  • Public hospitals provided the majority of safety-net services in the four cities visited.
  • Although only Los Angeles' health care safety net was considered by Lewin to be "in crisis" (in New York a crisis was thought to be imminent; in Memphis the safety net was under pressure; and in Dallas there was not a crisis), the level of need for health care services was considered high in all four cities.
  • Leadership was a key component for stability of safety-net systems.
  • More primary care capacity was needed but there were many barriers to its development.
  • Integration of health care delivery with public-health functions was difficult.
  • Most safety-net providers were not well positioned for managed care.
  • The rapid implementation of Medicaid managed care had shaken up health care delivery, but because of a lack of data, its impact on indigent care was uncertain.

Key Recommendations

  • The research team recommended that RWJF fund a concept they called the safety network, which would introduce a neutral agency that could provide information and technical assistance and promote communication and cooperation among urban safety net providers.

Funding
RWJF supported this project through a grant of $188,300.

 See Grant Detail & Contact Information
 Back to the Table of Contents


THE PROBLEM

The early and mid-1990s was a time of significant change and upheaval in the provision of health care and health insurance in the United States. Federal, state, and local budget cuts resulted in the fraying of the health and social safety net. In addition, price competition in the private insurance market and in Medicaid and Medicare managed care was forcing excess capacity out the health care system. The changes helped rid the system of deeply rooted inefficiencies, but, at the same time, those forces posed challenges — including financial sustainability — to the core of the health care safety net. This was especially true in America's urban areas where public hospitals, community health centers, public health departments, not-for-profit hospitals, and other safety-net providers were vital means of access to health care for many of the nation's poor.

 Back to the Table of Contents


THE PROJECT

The purpose of this project was to take a snapshot of the state of the health care safety net in four urban areas, and to make program development recommendations regarding the maintenance and improvement of the health care safety net. (A similar grant was awarded to Kalkines, Arky, Zall, & Bernstein [ID# 027417] to assess the viability of the safety net in three other cities (Boston, Miami, Philadelphia) and also in New York City.) The Lewin Group completed four major tasks to achieve the objectives:

  • Briefing books for the four urban centers: Dallas, Los Angeles, Memphis, and New York City were compiled by Lewin in preparation for the site visits. The briefing books provided an overview of access to health care in each city, as well as demographic information, background material about specific public and/or private care-giving institutions, and descriptions of the key political and economic pressures. Each briefing book contained press clippings, research documents, and other data drawn from a wide range of sources.
  • Site visits were scheduled and organized to all four cities. Accompanied by Foundation staff, Lewin staff interviewed key leaders and policymakers about the factors affecting the viability of each city's health care safety net. Interviewees included administrators of public hospitals and academic health centers, public health and public hospital advocates, and governmental organizations. Site visit summaries were prepared by Lewin after the visits. Each summary included a brief description of the local environmental context, an assessment of need within the city, brief descriptions of the key players and major forces impacting the delivery of care to those in need, as well as a brief discussion of potential grantmaking roles and options for the Foundation.
  • Program development recommendations were analyzed based on the results of the site visits.
  • A final presentation on the state of the health care safety net and program development recommendations was delivered with a slide presentation to RWJF staff. This presentation was accepted as the final narrative report.

 Back to the Table of Contents


FINDINGS

State of the Safety Net

  • Safety-net providers delivered a wide range of services, but an integrated "net" was noticeably absent.
  • Public hospitals provided the majority of safety-net services in the four cities visited.
  • Although only Los Angeles' health care safety net was considered by Lewin to be "in crisis" (in New York a crisis was thought to be imminent; in Memphis the safety net was under pressure; and in Dallas there was not a crisis), the level of need for health care services was considered high in all four cities.
  • Leadership was a key component for stability of safety-net systems.
  • More primary care capacity was needed but there were many barriers to its development.
  • Integration of health care delivery with public-health functions was difficult.
  • Most safety-net providers were not well positioned for managed care. Both reductions in government funding and changes in the nature of payment for hospital and other services for the poor threatened the financial stability of many of the providers and severely reduced their ability to compete with other providers.
  • The rapid implementation of Medicaid managed care had shaken up health care delivery, but because of a lack of data, its impact on indigent care was uncertain.

Recommendations for Program Development

Based on results from the site visits, Lewin recommended that the Foundation fund a concept they called the safety network. The purpose of the safety network was to introduce a neutral agency that could provide information and technical assistance and promote communication and cooperation among urban safety net providers.

Communications

Although communication was not formally supported by the grant, Lewin prepared an article, "The Status of Local Heath Care Safety Nets," (authors R Baxter and R Mechanic), based partly on the results of this project, which was published in the July/August 1997 issue of Health Affairs.

 Back to the Table of Contents


GRANT DETAILS & CONTACT INFORMATION

Project

Analysis of Options to Help Remake the Health Care Safety Net: Part II

Grantee

The Lewin Group, Inc. (Fairfax,  VA)

  • Amount: $ 188,300
    Dates: October 1995 to March 1996
    ID#:  028039

Contact

Raymond Baxter, Ph.D.
(703) 218-5640
rjbaxter@lewin.com

 Back to the Table of Contents


Report prepared by: Avery Hart
Reviewed by: Marie Lyons
Reviewed by: Molly McKaughan
Program Officer: Michael Beachler

Most Requested