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In Reply: Mr Aviles and Ms O’Connell take exception with our finding that hospitals with a higher percentage of Medicaid patients have lower baseline performance on average than other hospitals. We do not suggest that all safety-net hospitals have low performance, but that on average baseline hospital performance is lower if the percentage of patients insured by Medicaid is higher. This finding is consistent with numerous other studies that have found that a hospital's payer mix, its ownership (ie, public hospitals), and the race and socioeconomic status of its patients influence hospital performance^1-3 and suggests that safety-net hospitals face barriers to performing well on these measures.

We agree with O’Connell that safety-net hospitals are a heterogeneous group. For this reason, we did not categorize hospitals as safety-net or non–safety-net hospitals, as O’Connell suggests. Rather, we document a continuous relationship between the percentage of patients insured by Medicaid at a hospital . . . [Full Text of this Article]

Rachel M. Werner, MD, PhD
rwerner@mail.med.upenn.edu
Center for Health Equity Research and Promotion
Philadelphia Veterans Affairs Medical Center
Philadelphia, Pennsylvania

L. Elizabeth Goldman, MD, MCR
Department of Medicine

R. Adams Dudley, MD, MBA
Institute for Health Policy Studies
University of California, San Francisco

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