How Should We Use the Net in the Safety Net?

As a resident, I trained at Philadelphia General Hospital. Following training, for many years, I was a surgeon at Denver General, now Denver Health. Most knew it as “the knife and gun club” because it was the pre-eminent trauma center for the City and County of Denver and still is. Someone even published a book about the place and the people who worked there. In the late 70s, many of the staff had served in Vietnam, so they were highly skilled and dedicated people who had a strong sense of social purpose and were highly engaged. Most were underpaid compared to colleagues in private practice.

Safety net hospitals, like Denver Health and Philadelphia General, in addition to being mythical backdrops for medical TV dramas, are a critical component of the US sick care system of systems. Like all the other pieces of the system, e.g. VA hospitals, academic medical centers, Public Health and Indian Health Service Hospitals, each has its own culture, ethos and "feel." I've had the experience of working in most of those types of hospitals which has provided me with a broad, eclectic exposure to various patient populations and their clinical problems.

Here are some things you should know about safety net hospitals:

• In 1995, Medicaid and uninsured patients comprised 74% of discharges and 77% of outpatient visits at safety net hospitals.

• Medicaid, Medicare, and local subsidies accounted for more than 67% of safety net hospitals' total revenue; payments from commercial insurers comprised 15.7% of total revenues.

• Safety net hospitals provide a disproportionate share of some services for both privately insured and Medicare patients, including nearly three times their share of burn patients and more than two times their share of transplant and AIDS patients.

• Although safety net hospitals accounted for only 20.4% of inpatient days in 1993, they delivered 33.5% of neonatal intensive care, 37.7% of burn care, and 43.4% of pediatric intensive care for their communities.

Since that report, like all things sick care, the environment has substantially changed and safety net hospitals face major threats.

Forty years later, to address some of those threats, we are trying to integrate the Net into the safety net, using digital health products and services to achieve the quadruple aim of improving outcomes and population health, reducing per capita costs, and improving the patient and doctor experience. The challenges in underserved populations, however, are unique in many respects:

1. Almost 20% of the US population still lacks access to broadband.

2. Thirty million Americans are still uninsured. Many more are underinsured.

3. The majority of patients, particularly more recently, do not use English as their primary language. Denver General had a translation service providing translators for over 90 languages

4. Cultural norms for certain populations affect how they comply with treatment recommendations.

5. The poor own cell phones. Americans who live in households whose income is below the federal “poverty” level typically have cell phones (as well as landline phones), computers, televisions, video recorders, air conditioning, refrigerators, gas or electric stoves, washers and dryers, and microwaves.

In fact, 80.9% of households below the poverty level have cell phones, and a healthy majority—58.2%—have computers.

6. Medicaid patients and the uninsured continue to demonstrate high rates of inappropriate ER use and hospital readmissions, despite expansion of coverage in many states.

7. Socioeconomic determinants of health disparities and major risk factor habits are an important consideration in almost every patient seen in safety net hospitals. For example, getting Medicaid patients to stop smoking is a major challenge. Behavioral and mental health problems are pervasive. Homelessness is routine.

8. Safety net hospitals are at the nexus of not just medical technologies but immigration policy, law enforcement, social services, child welfare and the prison system.

9. Government owned and administered safety net hospitals have their own organizational culture and funding challenges that can interfere with clinical innovation.

Serving the underserved is a particular challenge. Digital health products can help, but, like all other products, will only have impact if they deliver user defined value where, when and how the users, including doctors, want them to.