When money is the mission--the high costs of investor-owned care

Effect of profit status in facilities on the mortality of patients on long-term haemodialysis: a nationwide cohort study

OBJECTIVES

Over the past two decades, debates on whether the profit status of dialysis facilities influences patient prognosis have been popular in the USA. Taiwan is one of the regions with the highest rate per capita of kidney replacement therapy worldwide, but no similar research has been conducted to date. This is the first study to address this issue.

DESIGN

This was a nationwide retrospective cohort study based on the Taiwan Renal Registry Data System.

SETTING

Patients were categorised into two groups based on the profit status (for-profit, not-for-profit (NFP)) of dialysis facilities, with 31 350 patients in each group. The patients were followed up from 2005 to 2012.

PARTICIPANTS

Patients with uraemia who underwent long-term haemodialysis in private dialysis facilities and public facilities were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Survival analyses were performed to compare prognosis between the two groups. Adjustments to patients' basic profile, and facilities' geographical distribution, level, and length of ownership were carried out to minimise possible confounding effects.

RESULTS

Analysis revealed that NFP dialysis facilities had better outcomes (HR=0.91, 95% CI (0.89 to 0.93)). A favourable effect remains with the adjustment of the facilities' level, geographical distribution (HR=0.89, 95% CI (0.86 to 0.93)) or length of ownership (HR=0.95, 95% CI (0.89 to 0.95)). Survival analysis based on the geographical distribution and level of facilities was also conducted, which showed better prognosis in medical centres in the six municipalities, whereas worse prognosis was found in local hospitals not located in these municipalities.

CONCLUSION

Our findings suggest that in contemporary settings in Taiwan, treatment at NFP dialysis facilities was associated with a better prognosis. The results should be interpreted with caution since the possibility of residual confounding effects and uncertainty of casual relations exist due to the nature of observational studies.

Investor-owned Health Care: The Hidden Blight on America's "System"

Investor ownership of US health care has grown exponentially in the past 50 years through ever closer ties with Wall Street corporate interests. More recently, private equity firms have accelerated this process, invariably with harmful impacts on access to affordable care, its quality, and profiteering, with little accountability. These impacts are fueled by several concurrent trends: (1) increasing privatization, (2) consolidation and mergers, (3) increasing bureaucracy and waste, and (4) profiteering that may bleed into outright fraud. This article traces the uncontrolled growth of health care costs and prices in recent decades, together with documented examples across the health care delivery system whereby profit-driven, investor-owned interests have compromised patient care. These include hospitals, emergency care, nursing homes, mental health, and practices of such specialities as obstetrics-gynecology and ophthalmology. These practices have compromised patient care in the midst of a pandemic and economic downturn, as reflected by markers of a system needing reform. A larger role of government is called for, together with the advantages of Medicare for All in establishing health care as a human right, not a privilege based on ability to pay.

Crisis in U.S. Health Care: Corporate Power Still Blocks Reform

The corporate, largely privatized market-based U.S. health care system is deteriorating in terms of increasing costs, decreasing access, unacceptable quality of care, inequities, and disparities. Reform efforts to establish universal insurance coverage have failed on six occasions over the last century, largely through opposition of corporate stakeholders in the medical-industrial complex. This article provides historical perspective to previous reform attempts, updates the current battle between Republicans and Democrats over repeal of the 2010 Affordable Care Act (ACA), and compares three financing alternatives-continuation of the ACA; its replacement by a Republican plan (the House's American Health Care Act or its Senate counterpart, the Better Care Reconciliation Act); and single-payer national health insurance (NHI or Medicare for All). Markers are described that reveal the extent of the current crisis in U.S. health care. Evidence is presented that the private insurance industry, increasingly dependent on bailout by the government, is in a "death spiral." NHI is gaining increasing public support as the only financing alternative to provide universal coverage. Nine lessons that are still unlearned in the United States concerning health care are discussed, together with future prospects to establish universal coverage in this embattled and changing political environment.

Payments and quality of care in private for-profit and public hospitals in Greece

BACKGROUND

Empirical evidence on how ownership type affects the quality and cost of medical care is growing, and debate on these topics is ongoing. Despite the fact that the private sector is a major provider of hospital services in Greece, little comparative information on private versus public sector hospitals is available. The aim of the present study was to describe and compare the operation and performance of private for-profit (PFP) and public hospitals in Greece, focusing on differences in nurse staffing rates, average lengths of stay (ALoS), and Social Health Insurance (SHI) payments for hospital care per patient discharged.

METHODS

Five different datasets were prepared and analyzed, two of which were derived from information provided by the National Statistical Service (NSS) of Greece and the other three from data held by the three largest SHI schemes in the country. All data referred to the 3-year period from 2001 to 2003.

RESULTS

PFP hospitals in Greece are smaller than public hospitals, with lower patient occupancy, and have lower staffing rates of all types of nurses and highly qualified nurses compared with public hospitals. Calculation of ALoS using NSS data yielded mixed results, whereas calculations of ALoS and SHI payments using SHI data gave results clearly favoring the public hospital sector in terms of cost-efficiency; in all years examined, over all specialties and all SHI schemes included in our study, unweighted ALoS and SHI payments for hospital care per discharge were higher for PFP facilities.

CONCLUSIONS

In a mixed healthcare system, such as that in Greece, significant performance differences were observed between PFP and public hospitals. Close monitoring of healthcare provision by hospital ownership type will be essential to permit evidence-based decisions on the future of the public/private mix in terms of healthcare provision.

Work or Place? Assessing the Concurrent Effects of Workplace Exploitation and Area-of-Residence Economic Inequality on Individual Health

Building on previous multilevel studies in social epidemiology, this cross-sectional study examines, simultaneously, the contextual effects of workplace exploitation and area-of-residence economic inequality on social inequalities in health among low-income nursing assistants. A total of 868 nursing assistants recruited from 55 nursing homes in Kentucky, Ohio, and West Virginia were surveyed between 1999 and 2001. Using a cross-classified multilevel design, the authors tested the effects of area-of-residence (income inequality and racial segregation), workplace (type of nursing home ownership and managerial pressure), and individual-level (age, gender, race/ethnicity, health insurance, length of employment, social support, type of nursing unit, preexisting psychopathology, physical health, education, and income) variables on health (self-reported health and activity limitations) and behavioral outcomes (alcohol use and caffeine consumption). Findings reveal that overall health was associated with both workplace exploitation and area-of-residence income inequality; area of residence was associated with activity limitations and binge drinking; and workplace exploitation was associated with caffeine consumption. This study explicitly accounts for the multiple contextual structure and effects of economic inequality on health. More work is necessary to replicate the current findings and establish robust conclusions on workplace and area of residence that might help inform interventions.

In the business of dying: questioning the commercialization of hospice

This article critically questions the commercialization of hospice care and the ethical concerns associated with the industry's movement toward "market-driven medicine" at the end of life. For example, the article examines issues raised by an influx of for-profit hospice providers whose business model appears at its core to have an ethical conflict of interest between shareholders doing well and terminal patients dying well. Yet, empirical data analyzing the experience of patients across the hospice industry are limited, and general claims that end-of-life patient care is inferior among for-profit providers or even that their business practices are somehow unseemly when compared to nonprofit providers cannot be substantiated. In fact, non-profit providers are not immune to potentially conflicting concerns regarding financial viability (i.e., "no margin, no mission"). Given the limitations of existing empirical data and contrasting ideological commitments of for-profit versus non-profit providers, the questions raised by this article highlight important areas for reflection and further study. Policymakers and regulators are cautioned to keep ethical concerns in the fore as an increasingly commercialized hospice industry continues to emerge as a dominant component of the U.S. health care system. Both practitioners and researchers are encouraged to expand their efforts to better understand how business practices and commercial interests may compromise the death process of the patient and patient's family--a process premised upon a philosophy and ethical tradition that earlier generations of hospice providers and proponents established as a trusted, end-of-life alternative.

The influence of facility ownership structure on individual responding to stress: a multilevel model

Few studies have investigated the effect of health-care facility ownership on the relationship between patient stressors and coping strategies. The purpose of this study was to investigate whether haemodialysis (HD) patient stressors and coping strategies differ by type of health-care facility ownership, and whether such ownership has a cross-level moderating effect between stressors and coping strategies. We used the Haemodialysis Stressor Scale and the Jalowiec Coping Scale; primary data were collected by interviewing 2642 HD patients 15 years or older on dialysis for at least three months from 27 HD centres. One-way analysis of variance and hierarchical linear modelling were used to attain the research purposes. HD patients from religious-based hospitals had higher stress related to their physical symptoms, dependency on medical staff, role ambiguity and blood vessel problems than those differently owned facilities. Patients in veterans and army (VA) hospitals had higher stress related to food and fluid restriction and dependency on medical staff than private centres. Patients in religious-based hospitals had significantly higher coping scores, followed by VA and private HD centres. Religion-based ownership might serve as a cross-level moderator for patients perceiving role ambiguity stress and using problem-oriented, support seeking and isolated thought-coping strategies.

Colombia and Cuba, contrasting models in Latin America's health sector reform

Latin American national health systems were drastically overhauled by the health sector reforms the 1990s. Governments were urged by donors and by the international financial institutions to make major institutional changes, including the separation of purchaser and provider functions and privatization. This article first analyses a striking paradox of the far-reaching reform measures: contrary to what is imposed on public health services, after privatization purchaser and provider functions are reunited. Then we compare two contrasting examples: Colombia, which is internationally promoted as a successful--and radical--example of 'market-oriented' health care reform, and Cuba, which followed a highly 'conservative' path to adapt its public system to the new conditions since the 1990s, going against the model of the international institutions. The Colombian reform has not been able to materialize its promises of universality, improved equity, efficiency and better quality, while Cuban health care remains free, accessible for everybody and of good quality. Finally, we argue that the basic premises of the ongoing health sector reforms in Latin America are not based on the people's needs, but are strongly influenced by the needs of foreign--especially North American--corporations. However, an alternative model of health sector reform, such as the Cuban one, can probably not be pursued without fundamental changes in the economic and political foundations of Latin American societies.

The risk of upcoding in casemix systems: a comparative study

With the introduction of a diagnosis related group (DRG) classification system in the Netherlands in 2005 it has become relevant to investigate the risk of upcoding. The problem of upcoding in the US casemix system is substantial. In 2004, the US Centres for Medicare and Medicaid estimated that the total number of improper Medicare payments for the Prospective Payment system for acute inpatient care (both short term and long term) amounted to US$ 4.8 billion (5.2%). By comparing the casemix systems in the US, Australian and Dutch healthcare systems, this article illustrates why certain casemix systems are more open to the risk of upcoding than other systems. This study identifies various market, control and casemix characteristics determining the weaknesses of a casemix reimbursement system to upcoding. It can be concluded that fewer opportunities for upcoding occur in casemix systems that do not allow for-profit ownership and in which the coder's salary does not depend on the outcome of the classification process. In addition, casemix systems in which the first point in time of registration is at the beginning of the care process and in which there are a limited number of occasions to alter the registration are less vulnerable to the risk of upcoding. Finally, the risk of upcoding is smaller in casemix systems that use classification criteria that are medically meaningful and aligned with clinical practice. Comparing the US, Australian and Dutch systems the following conclusions can be drawn. Given the combined occurrences of for-profit hospitals and the use of the secondary diagnosis criterion to classify DRGs, the US casemix system tends to be more open to upcoding than the Australian system. The strength of the Dutch system is related to the detailed classification scheme, using medically meaningful classification criteria. Nevertheless, the detailed classification scheme also causes a weakness, because of its increased complexity compared with the US and Australian system. It is recommended that researchers and policy makers carefully consider all relevant market, control and casemix characteristics when developing and restructuring casemix reimbursement systems.

The role of tax exemption in a competitive health care market

The Federal Trade Commission and Department of Justice 2004 report on competition in health care raises the issue of nonprofit versus for-profit form in several contexts, including their relative financial performance, pricing behavior, and role in caring for the uninsured poor. The report, however, does not discuss in detail the connection between tax exemption and the nonprofit/for-profit debate. Is tax exemption, for example, "buying" charity care for the poor, and would withdrawal of exemption negatively impact health care for the uninsured poor? Or is tax exemption justified on the grounds of other nonprofit behavior outside the financial realm and thus not considered by the report? If nonprofit status does not result in differential financial behavior (as the report concludes) and if competition will end the ability of hospitals to cross subsidize free care for the poor (as the report speculates), is there any reason to retain tax exemption for nonprofit hospitals? This article summarizes the debate on these issues and offers some alternatives to the current structure of tax exemption for nonprofit health care providers.

Privatization of Medicare: toward disentitlement and betrayal of a social contract

An intense political battle is being waged over the future of U.S. Medicare. The 40-year social contract established with the nation's elderly and disabled is seriously threatened. The basic issue is whether Medicare will remain a universal entitlement program or be privatized and dismantled as an obligation of government. Faced with the growing costs of the Medicare program, changing demographics of an aging population, and long-term federal deficits, conservative interests are promoting further privatization of the program under the guise of increasing beneficiaries' choice and the claimed efficiency of the private marketplace. Following a historical overview of past efforts to privatize Medicare, this article reviews the track record of private Medicare plans over the last 20 years with regard to choice, reliability, cost containment, benefits, quality of care, efficiency, public satisfaction, and fraud. In all of these areas, privatized Medicare has performed less well than original Medicare. Based on the evidence, one has to conclude that privatization of Medicare is detrimental to the elderly and disabled, the most vulnerable groups in our society, and that the only winners in that transformation are private market interests.

Comparing mission statement content in for-profit and not-for-profit hospitals: does mission really matter?

In this article, the author examined the content of mission statements in both the for-profit and not-for-profit hospital sectors. He used content analysis to compare and contrast the existence and frequency of words or phrases found in the mission statements of each sector. In particular, he analyzed the following three concepts: cost, access, and quality. The author found no significant differences in mission statement content across these three concepts when he compared investor-owned (for-profit) and nongovernmental not-for-profit hospitals. The results of this study suggest that the hospital industry lags behind other sectors in the design and development of thorough and complete mission statements. Hospital executives are encouraged to devote more time to the construction of hospital-specific and comprehensive mission statements that will provide important information for stakeholders, while simultaneously capturing the organization's unique purpose and niche in the competitive healthcare environment.

Strategic Management and Performance Differences

Despite mixed and contradictory findings, for-profits (FPs) and nonprofits (NPs) are assumed to be similar health services organizations (HSOs). In this study, a fifteen-item scale assessing HSOs' strategic management capacity was developed and tested using fifty-seven FP and twenty NP organizations. Then, using item response theory, the items were hierarchically profiled to produce two strategic profile models, a general and an FP anchored model. We find that deviation from the general profile, but not capability attainment level, is related to two of three financial measures. We conclude that studying FPs and NPs together is appropriate.

Payments for care at private for-profit and private not-for-profit hospitals: a systematic review and meta-analysis

BACKGROUND

It has been shown that patients cared for at private for-profit hospitals have higher risk-adjusted mortality rates than those cared for at private not-for-profit hospitals. Uncertainty remains, however, about the economic implications of these forms of health care delivery. Since some policy-makers might still consider for-profit health care if expenditure savings were sufficiently large, we undertook a systematic review and meta-analysis to compare payments for care at private for-profit and private not-for-profit hospitals.

METHODS

We used 6 search strategies to identify published and unpublished observational studies that directly compared the payments for care at private for-profit and private not-for-profit hospitals. We masked the study results before teams of 2 reviewers independently evaluated the eligibility of all studies. We confirmed data or obtained additional data from all but 1 author. For each study, we calculated the payments for care at private for-profit hospitals relative to private not-for-profit hospitals and pooled the results using a random effects model.

RESULTS

Eight observational studies, involving more than 350 000 patients altogether and a median of 324 hospitals each, fulfilled our eligibility criteria. In 5 of 6 studies showing higher payments for care at private for-profit hospitals, the difference was statistically significant; in 1 of 2 studies showing higher payments for care at private not-for-profit hospitals, the difference was statistically significant. The pooled estimate demonstrated that private for-profit hospitals were associated with higher payments for care (relative payments for care 1.19, 95% confidence interval 1.07-1.33, p = 0.001).

INTERPRETATION

Private for-profit hospitals result in higher payments for care than private not-for-profit hospitals. Evidence strongly supports a policy of not-for-profit health care delivery at the hospital level.

Medicare upcoding and hospital ownership

Many hospitals in the 1990s many hospitals were accused of "upcoding" patient diagnostic related groups (DRGs) to increase Medicare reimbursements. We find that between 1989 and 1996, the percentage point share of the most generous DRG for pneumonia and respiratory infections rose by 10 points among not-for-profit hospitals, 23 points among for-profit hospitals, and 37 points in hospitals converting to for-profit status. Not-for-profit upcoding was also higher in markets with a larger for-profit hospital share. Upcoding appears to reflect both risk-taking by administrators and a closer alignment between the goals of the administration and the behavior of the clinical staff.

Medicine and money: the ethical transformation of medical practice

OBJECTIVE

To explore the generalised application of a discourse of cost reduction in the practice of medicine in the USA.

CONTEXT

Changes in the health services industry over the last 20 years have left much concern in the hearts and minds of many, providers and patients alike. Even for the millions of Americans who are able to purchase health insurance, the standard of care has changed. In some ways, the current managed-care climate has created an atmosphere of distrust between patients and their providers, and, more significantly, a general sense of dissatisfaction with the state of health care in the USA. In the midst of this discontent, health providers have begun to question their own roles in what is increasingly a for-profit health care system. Not surprisingly, medical educators now question whether the current health system is creating a new generation of doctors who are concerned with reducing costs without adequate review of clinical data.

METHODS

This paper examines the rationale applied in the management of a patient with end-stage liver disease in a teaching hospital. The case is re-socialised by situating it in an ethical discourse linked to the function of the for-profit health system.

RESULTS

The decision about whether to give human albumin to an insured patient serves as a lens through which to examine how uncritical appeals to the discourse of 'cost-effectiveness' can supersede a patient- and data-oriented approach to medical decision making.

CONCLUSIONS

This case illustrates the permeation of economic considerations into the core values of medicine, highlighting a detrimental ethical shift occurring in the field. The training of new doctors represents a site from which to resist this unwelcome transformation.

Quality standards for health care delivery and management in publicly oriented health services

In 1999, the multidisciplinary Tavistock group prepared a generic statement of ethical principles to govern health care systems. This paper elaborates on these principles in two directions. First, it develops a set of quality standards, based on ethical principles, intended to regulate health care delivery and service management. Second, it focuses them on 'publicly oriented' (not necessarily governmental) as opposed to 'for profit' (not necessarily private) services. We propose ten principles or quality standards for these services, part of which relate to the individual patients, others to the community. They are political as well as technical, and can be used to inspire health policies, contracts issued by governments, and identification of partners by aid agencies. We analyse their application in key areas of health care by publicly oriented and for-profit health care organizations standards in developing countries, and conclude that the latter are unlikely to adopt the proposed standards. We further elaborate on the implications of the standards for publicly oriented services, focusing on care delivery and patient-centred care, family and community medicine, services management and disease control. Using these criteria for a renewed compact between authorities, health professionals and communities may help to motivate health professionals by bridging the gap between their professional and social-political identity.

Providing health care for older persons in Singapore

Health care social policy in Singapore has passed the burden of care to the individual and the family on the rationale that it would enable the state to contain the costs of long-term care by channelling some of its funds to community services and to providing essential health services to all Singaporeans and not just the older group. While a wide array of services has come into existence, there is a lack of integration between the available resources and needs of the individual/family and what has been availed at the community and state levels. Part of the problem lies in the stringent criteria to which the state allows subsidies to be used; the lack of understanding with regard to the profile of users of services; and the case manager approach in offering services. Mapping health care has proven more difficult than anticipated because ageing is a diverse experience, varying by gender, race, income, religion and intergenerational relationships. A social policy does not apply to a 'universal citizen' and services that exist in the public sphere should not exist as merely commodified services which require a great deal of institutional processing.

Managed care or managed inequality? A call for critiques of market-based medicine

This review article critiques the growing dominance of market-based medicine in the United States against the background of existing problems with quality of care, rising costs, devaluation of doctor-patient relationships, and, especially, persistent inequalities of access and outcomes. It summarizes the present state of health care delivery by focusing on the concurrent trends of growth in managed care, expanding profits, increasing proportion of those uninsured, and widening racial, ethnic, and class disparities in access to care. Allowing market forces to dictate the shape of health care delivery in this country ensures that inequalities will continue to grow and modern medicine will become increasingly adept at managing inequality rather than managing (providing) care. The article challenges anthropology to become more involved in critiquing these developments and suggests how anthropologists can expand on and contextualize debates surrounding the market's role in medicine, here and abroad.

Does investor-ownership of nursing homes compromise the quality of care?

Quality problems have long plagued the nursing home industry. While two-thirds of U.S. nursing homes are investor-owned, few studies have examined the impact of investor-ownership on the quality of care. The authors analyzed 1998 data from inspections of 13,693 nursing facilities representing virtually all U.S. nursing homes. They grouped deficiency citations issued by inspectors into three categories ("quality of care," "quality of life," and "other") and compared deficiency rates in investor-owned, nonprofit, and public nursing homes. A multivariate model was used to control for case mix, percentage of residents covered by Medicaid, whether the facility was hospital-based, whether it was a skilled nursing facility for Medicare only, chain ownership, and location by state. The study also assessed nurse staffing. The authors found that investor-owned nursing homes provide worse care and less nursing care than nonprofit or public homes. Investor-owned facilities averaged 5.89 deficiencies per home, 46.5 percent higher than nonprofit and 43.0 percent higher than public facilities, and also had more of each category of deficiency. In the multivariate analysis, investor-ownership predicted 0.679 additional deficiencies per home; chain-ownership predicted an additional 0.633 deficiencies per home. Nurse staffing ratios were markedly lower at investor-owned homes.

Effect of medicare payment on rural health care systems

Medicare payments constitute a significant share of patient-generated revenues for rural providers, more so than for urban providers. Therefore, Medicare payment policies influence the behavior of rural providers and determine their financial viability. Health services researchers need to contribute to the understanding of the implications of changes in fee-for-service payment policy, prospects for change because of the payment to Medicare+Choice risk plans, and implications for rural providers inherent in any restructuring of the Medicare program. This article outlines the basic policy choices, implications for rural providers and Medicare beneficiaries, impacts of existing research, and suggestions for further research. Topics for further research include implications of the Critical Access Hospital program, understanding how changes in payment to rural hospitals affect patient care, developing improved formulas for paying rural hospitals, determining the payment-to-cost ratio for physicians, measuring the impact of changes in the payment methodology used to pay for services delivered by rural health clinics and federally qualified health centers, accounting for the reasons for differences in historical Medicare expenditures across rural counties and between rural and urban counties, explicating all reasons for Medicare+Choice plans withdrawing from some rural areas and entering others, measuring the rural impact of proposals to add a prescription drug benefit to the Medicare program, and measuring the impact of Medicare payment policies on rural economies.

Does investor ownership of nursing homes compromise the quality of care?

OBJECTIVES

Two thirds of nursing homes are investor owned. This study examined whether investor ownership affects quality.

METHODS

We analyzed 1998 data from state inspections of 13,693 nursing facilities. We used a multivariate model and controlled for case mix, facility characteristics, and location.

RESULTS

Investor-owned facilities averaged 5.89 deficiencies per home, 46.5% higher than nonprofit facilities and 43.0% higher than public facilities. In multivariate analysis, investor ownership predicted 0.679 additional deficiencies per home; chain ownership predicted an additional 0.633 deficiencies. Nurse staffing was lower at investor-owned nursing homes.

CONCLUSIONS

Investor-owned nursing homes provide worse care and less nursing care than do not-for-profit or public homes.

Aging and the market in the United States

Current Social Security reform proposals in the United States presume that, as long as the cash income of future retirees is secure, private businesses will take care of producing just the goods and services an aging population requires. However, the performance of private nursing homes, assisted-living complexes, pharmaceuticals, health, insurance, and transportation services for the elderly raises serious questions about the ability of markets to cater to the needs of a vulnerable population. Industries that specialize in goods and services for the old face repeated accusations of fraud, overcharging, poor service, and deceptive practices. The article reports on research on the performance of a number of industries that serve the aged. A careful look at these markets should caution us against relying too heavily on private markets to serve an aging population. The surplus funds flowing into Social Security might be better employed financing the kinds of public services for the elderly that private markets have so far failed to deliver.

Fatal distraction: finance versus vigilance in U.S. hospitals

Three decades ago, a now classic study on the sale of human blood defied conventional economic wisdom by demonstrating that a marketplace system for blood distribution was less efficient, less safe, and more costly. Emerging data, including the article by Thomas and colleagues in this issue, suggest the same may be true for hospitals. For-profit hospitals in Utah and Colorado had higher preventable adverse event rates than matched nonprofits. The author explores possible explanations, including the role of nursing care. While some claimed that a for-profit marketplace would stimulate efforts for improved quality, evidence is accumulating that report cards and profit-driven competition have failed to deliver on their promises. More promising is a series of not-for-profit initiatives to reduce errors that redirects our attention to patients and their need for better quality care. Rather than allowing competition to lower costs and avoid sick patients to distract us, our energies need to focus on better quality alternatives.

Hospital ownership and cost and quality of care: is there a dime's worth of difference?

Nonprofit organizations may predominate when output quality is difficult to monitor. Hospital care has this characteristic. This study compared program cost and quality of care for Medicare patients hospitalized following onset of four common conditions by hospital ownership. Payments on behalf of Medicare patients admitted to for-profit hospitals during the first 6 months following a health shock were higher than for those admitted to other hospitals. With quality measured in terms of survival, changes in functional and cognitive status, and living arrangements, we found no differences in outcomes by hospital ownership.

Health policy and legislation: impact on cancer nursing and care

OBJECTIVES

To review policy and legislative initiatives in which nursing has played roles and to provide insight into trends and issues that characterize the policy and political agendas in which oncology nurses can play advocacy roles in the new millennium.

DATA SOURCES

Professional journals, books, newspapers, news magazines, and internet web sites.

CONCLUSIONS

Oncology nurses can offer solutions to the dilemmas posed by fiscal realities, unique American values and expectations, and the complexities of cancer care in the United State's market-based health care system. Oncology nurses must assume roles as health policy specialists.

IMPLICATIONS FOR NURSING PRACTICE

For nurses to gain acceptance in health policy arenas, individual nurses and groups of nurses must become expert in assessing the environment, the interpretation of cues, and the development and implementation of realistic strategies targeting priority health policy and legislative issues.