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Bayindir EE, Schreyögg J. What drives different treatment choices? Investigation of hospital ownership, system membership and competition. HEALTH ECONOMICS REVIEW 2021; 11:6. [PMID: 33591431 PMCID: PMC7885748 DOI: 10.1186/s13561-021-00305-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 02/04/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Differences in ownership types have attracted considerable interest because of policy implications. Moreover, competition in hospital markets is promoted to reduce health care spending. However, the effects of system membership and competition on treatment choices of hospitals have not been considered in studying hospital ownership types. We examine the treatment choices of hospitals considering ownership types (not-for-profit, for-profit, and government), system membership, patient insurance status (insured, and uninsured) and hospital competition in the United States. METHODS We estimate the probability of according the procedure as the treatment employing logistic regression. We consider all procedures accorded at hospitals, controlling for procedure type and diagnosis as well as relevant patient and hospital characteristics. Competition faced by hospitals is measured using a distance-weighted approach separately for procedural groups. Patient records are obtained from State Inpatient Databases for 11 states and hospital characteristics come from American Hospital Association Annual Survey. RESULTS Not-for-profit hospitals facing low for-profit competition that are nonmembers of hospital systems, act like government hospitals, whereas not-for-profits facing high for-profit competition and system member not-for-profits facing low for-profit competition are not statistically significantly different from their for-profit counterparts in terms of treatment choices. Uninsured patients are on average 7% less likely to be accorded the procedure as the treatment at system member not-for-profit hospitals facing high for-profit competition than insured patients. System member not-for-profit hospitals, which account for over half of the observations in the analysis, are on average 16% more likely to accord the procedure as the treatment when facing high for-profit competition than low-for-profit competition. CONCLUSIONS We show that treatment choices of hospitals differ by system membership and the level of for-profit competition faced by the hospitals in addition to hospital ownership type and health insurance status of patients. Our results support that hospital system member not-for-profits and not-for-profits facing high for-profit competition are for-profits in disguise. Therefore, system membership is an important characteristic to consider in addition to market competitiveness when tax exemption of not-for-profits are revisited. Moreover, higher competition may lead to increasing health care costs due to more aggressive treatment choices, which should be taken into account while regulating hospital markets.
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Affiliation(s)
- Esra Eren Bayindir
- Hamburg Center for Health Economics, University of Hamburg, Hamburg, Germany
| | - Jonas Schreyögg
- Hamburg Center for Health Economics, University of Hamburg, Hamburg, Germany.
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Establishing a Baseline: Community Benefit Spending by Not-for-Profit Hospitals Prior to Implementation of the Affordable Care Act. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2018; 23:e1-e9. [PMID: 27997478 PMCID: PMC5636059 DOI: 10.1097/phh.0000000000000493] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is Available in the Text. Context: Community Benefit spending by not-for-profit hospitals has served as a critical, formalized part of the nation's safety net for almost 50 years. This has occurred mostly through charity care. This article examines how not-for-profit hospitals spent Community Benefit dollars prior to full implementation of the Affordable Care Act (ACA). Methods: Using data from 2009 to 2012 hospital tax and other governmental filings, we constructed national, hospital-referral-region, and facility-level estimates of Community Benefit spending. Data were collected in 2015 and analyzed in 2015 and 2016. Data were matched at the facility level for a non-profit hospital's IRS tax filings (Form 990, Schedule H) and CMS Hospital Cost Report Information System and Provider of Service data sets. Results: During 2009, hospitals spent about 8% of total operating expenses on Community Benefit. This increased to between 8.3% and 8.5% in 2012. The majority of spending (>80%) went toward charity care, unreimbursed Medicaid, and subsidized health services, with approximately 6% going toward both community health improvement and health professionals' education. By 2012, national spending on Community Benefit likely exceeded $60 billion. The largest hospital systems spent the vast majority of the nation's Community Benefit; the top 25% of systems spent more than 80 cents of every Community Benefit dollar. Discussion: Community Benefit spending has remained relatively steady as a proportion of total operating expenses and so has increased over time—although charity care remains the major focus of Community Benefit spending overall. Implications: More than $60 billion was spent on Community Benefit prior to implementation of the ACA. New reporting and spending requirements from the IRS, alongside changes by the ACA, are changing incentives for hospitals in how they spend Community Benefit dollars. In the short term, and especially the long term, hospital systems would do well to partner with public health, other social services, and even competing hospitals to invest in population-based activities. The mandated community health needs assessment process is a logical home for these sorts of collaborations. Relatively modest investments can improve the baseline level of health in their communities and make it easier to improve population health. Aside from a population health justification for a partnership model, a business case is necessary for widespread adoption of this approach. Because of their authorities, responsibilities, and centuries of expertise in community health, public health agencies are in a position to help hospitals form concrete, sustainable collaborations for the improvement of population health. Conclusion: The ACA will likely change the delivery of uncompensated and charity care in the United States in the years to come. How hospitals choose to spend those dollars may be influenced greatly by the financial and political environments, as well as the strength of community partnerships.
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Han J, Kairies-Schwarz N, Vomhof M. Quality competition and hospital mergers-An experiment. HEALTH ECONOMICS 2017; 26 Suppl 3:36-51. [PMID: 29285867 DOI: 10.1002/hec.3574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/25/2017] [Accepted: 07/05/2017] [Indexed: 06/07/2023]
Abstract
On the basis of a Salop model with regulated prices, we investigate quality provision behaviour of competing hospitals before and after a merger. For this, we use a controlled laboratory experiment where subjects decided on the level of treatment quality as head of a hospital. We find that the post-merger average quality is significantly lower than the average pre-merger quality. However, for merger insiders and outsiders, average quality choices are significantly higher than predicted for pure profit-maximising hospitals. This upward deviation is potentially driven by altruistic behaviour towards patients. Furthermore, we find that in the case where sufficient cost synergies are realised by the merged hospitals, there is a significant increase in average quality choices compared to the scenario without synergies. Finally, we find that our results do not change when comparing individual decisions to team decisions.
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Affiliation(s)
- Johann Han
- Faculty of Economics and Business Administration, University of Duisburg-Essen & CINCH (Competent in Competition and Health), Essen, Germany
| | - Nadja Kairies-Schwarz
- Faculty of Economics and Business Administration, University of Duisburg-Essen & CINCH (Competent in Competition and Health), Essen, Germany
| | - Markus Vomhof
- Faculty of Economics and Business Administration, University of Duisburg-Essen & CINCH (Competent in Competition and Health), Essen, Germany
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Schlesinger M, Mitchell S, Gray B. Measuring Community Benefits Provided by Nonprofit and For-Profit HMOs. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2016; 40:114-32. [PMID: 13677560 DOI: 10.5034/inquiryjrnl_40.2.114] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Despite the dramatic shift from nonprofit to for-profit ownership in the managed care industry, little is known about the implications for health plans' relations with the communities in which they operate. This paper provides the first comprehensive comparison of the community benefit activities of nonprofit and for-profit health maintenance organizations (HMOs). We develop a conceptual framework for identifying these activities and provide evidence from a nationally representative survey of plans fielded in 1999. We find that nonprofit plans exceed their for-profit counterparts on some, but not all, aspects of community benefit activity. The most consistent ownership-related differences involve redistributive programs (subsidized services and general philanthropy), commitments to medical research, and services that benefit the entire local population, beyond the plan's enrollees. Other forms of community benefits show mixed or modest differences between nonprofit and for-profit plans. Unexpectedly, for-profit plans actually appear more active in helping consumers deal with information asymmetries. The paper concludes with a discussion of implications for policy and future research.
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Affiliation(s)
- Mark Schlesinger
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520, USA
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Rubin DB, Singh SR, Young GJ. Tax-exempt hospitals and community benefit: new directions in policy and practice. Annu Rev Public Health 2016; 36:545-57. [PMID: 25785895 DOI: 10.1146/annurev-publhealth-031914-122357] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The current community benefit standard for nonprofit hospital tax exemption has been the subject of mounting criticism. Many different constituencies have advanced the view that in its present form it fails to ensure that nonprofit hospitals provide adequate benefits to their communities in exchange for their tax exemption. In contrast, hospitals have often expressed the concern that the community benefit standard in its current form is vague and therefore difficult to comply with. Various suggestions have been made regarding how the existing community benefit standard could be improved or even replaced. In this article, we first discuss the historical and legal development of the community benefit standard. We then present the key controversies that have emerged in recent years and the policy responses attempted thus far. Finally, we evaluate possible future policy directions, which reform efforts could follow.
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Affiliation(s)
- Daniel B Rubin
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan 48109; ,
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Hernandez DD, Schneider H. Competitive Pressures and Access to Infertility Treatments by Single Women. Health (London) 2016. [DOI: 10.4236/health.2016.811109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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An examination of competition and efficiency for hospital industry in Turkey. Health Care Manag Sci 2014; 18:407-18. [DOI: 10.1007/s10729-014-9315-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 12/03/2014] [Indexed: 10/24/2022]
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Kondilis E, Gavana M, Giannakopoulos S, Smyrnakis E, Dombros N, Benos A. Payments and quality of care in private for-profit and public hospitals in Greece. BMC Health Serv Res 2011; 11:234. [PMID: 21943020 PMCID: PMC3199237 DOI: 10.1186/1472-6963-11-234] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 09/23/2011] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Elias Kondilis
- Greek Observatory on the Privatization of Health Care, Aristotle University, 54124 Thessaloniki, Greece
- Laboratory of Hygiene, Medical School, Aristotle University, 54124 Thessaloniki, Greece
| | - Magda Gavana
- Laboratory of Hygiene, Medical School, Aristotle University, 54124 Thessaloniki, Greece
| | | | - Emmanouil Smyrnakis
- Laboratory of Hygiene, Medical School, Aristotle University, 54124 Thessaloniki, Greece
| | - Nikolaos Dombros
- Medical School, Aristotle University, 54124 Thessaloniki, Greece
| | - Alexis Benos
- Greek Observatory on the Privatization of Health Care, Aristotle University, 54124 Thessaloniki, Greece
- Laboratory of Hygiene, Medical School, Aristotle University, 54124 Thessaloniki, Greece
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Yoon J. Effect of increased private share of inpatient psychiatric resources on jail population growth: Evidence from the United States. Soc Sci Med 2011; 72:447-55. [DOI: 10.1016/j.socscimed.2010.07.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Revised: 05/18/2010] [Accepted: 07/05/2010] [Indexed: 10/19/2022]
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Horwitz JR, Nichols A. Hospital ownership and medical services: market mix, spillover effects, and nonprofit objectives. JOURNAL OF HEALTH ECONOMICS 2009; 28:924-937. [PMID: 19781802 DOI: 10.1016/j.jhealeco.2009.06.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Revised: 06/09/2009] [Accepted: 06/10/2009] [Indexed: 05/28/2023]
Abstract
Hospitals operate in markets with varied demographic, competitive, and ownership characteristics, yet research on ownership tends to examine hospitals in isolation. Here we examine three hospital ownership types -- nonprofit, for-profit, and government -- and their spillover effects. We estimate the effects of for-profit market share in two ways, on the provision of medical services and on operating margins at the three types of hospitals. We find that nonprofit hospitals' medical service provision systematically varies by market mix. We find no significant effect of market mix on the operating margins of nonprofit hospitals, but find that for-profit hospitals have higher margins in markets with more for-profits. These results fit best with theories in which hospitals maximize their own output.
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Semansky RM, Altschul D, Sommerfeld D, Hough R, Willging CE. Capacity for delivering culturally competent mental health services in New Mexico: results of a statewide agency survey. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2009; 36:289-307. [PMID: 19370410 DOI: 10.1007/s10488-009-0221-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Accepted: 03/25/2009] [Indexed: 11/25/2022]
Abstract
The Federal government has promoted National Standards for Culturally and Linguistically Appropriate Services (CLAS) to reduce mental health disparities among Hispanic and Native American populations. In 2005, the State of New Mexico embarked upon a comprehensive reform of its behavioral health system with an emphasis on improving cultural competency. Using survey methods, we examine which language access services (i.e., capacity for bilingual care, interpretation, and translated written materials) and organizational supports (i.e., training, self-assessments of cultural competency, and collection of cultural data) mental health agencies in New Mexico had at the onset of a public sector mental health reform (Office of Minority Health 2001).
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Affiliation(s)
- Rafael M Semansky
- Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, Albuquerque, NM 87102, USA.
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Acosta-Ramírez N, Durán-Arenas LG, Eslava-Rincón JI, Campuzano-Rincón JC. Determinants of vaccination after the Colombian health system reform. Rev Saude Publica 2005; 39:421-9. [PMID: 15997318 DOI: 10.1590/s0034-89102005000300013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: To assess the effects of individual, household and healthcare system factors on poor children's use of vaccination after the reform of the Colombian health system. METHODS: A household survey was carried out in a random sample of insured poor population in Bogota, in 1999. The conceptual and analytical framework was based on the Andersen's Behavioral Model of Health Services Utilization. It considers two units of analysis for studying vaccination use and its determinants: the insured poor population, including the children and their families characteristics; and the health care system. Statistical analysis were carried out by chi-square test with 95% confidence intervals, multivariate regression models and Cronbach's alpha coefficient. RESULTS: The logistic regression analysis showed that vaccination use was related not only to population characteristics such as family size (OR=4.3), living area (OR=1.7), child's age (OR=0.7) and head-of-household's years of schooling (OR=0.5), but also strongly related to health care system features, such as having a regular health provider (OR=6.0) and information on providers' schedules and requirements for obtaining care services (OR=2.1). CONCLUSIONS: The low vaccination use and the relevant relationships to health care delivery systems characteristics show that there are barriers in the healthcare system, which should be assessed and eliminated. Non-availability of regular healthcare and deficient information to the population are factors that can limit service utilization.
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Xirasagar S, Lin HC. Cost convergence between public and for-profit hospitals under prospective payment and high competition in Taiwan. Health Serv Res 2004; 39:2101-16. [PMID: 15544646 PMCID: PMC1361114 DOI: 10.1111/j.1475-6773.2004.00334.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To test the hypotheses that: (1) average adjusted costs per discharge are higher in high-competition relative to low-competition markets, and (2) increased competition is associated with cost convergence between public and for-profit (FP) hospitals for case payment diagnoses, but not for cost-plus reimbursed diagnoses. DATA SOURCES Taiwan's National Health Insurance database; 325,851 inpatient claims for cesarean section, vaginal delivery, prostatectomy, and thyroidectomy (all case payment), and bronchial asthma and cholelithiasis (both cost-based payment). STUDY DESIGN Retrospective population-based, cross-sectional study. DATA ANALYSIS Diagnosis-wise regression analyses were done to explore associations between cost per discharge and hospital ownership under high and low competition, adjusted for clinical severity and institutional characteristics. PRINCIPAL FINDINGS Adjusted costs per discharge are higher for all diagnoses in high-competition markets. For case payment diagnoses, the magnitudes of adjusted cost differences between public and FP hospitals are lower under high competition relative to low competition. This is not so for the cost-based diagnoses. CONCLUSIONS We find that the empirical evidence supports both our hypotheses.
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Carlson MDA, Gallo WT, Bradley EH. Ownership status and patterns of care in hospice: results from the National Home and Hospice Care Survey. Med Care 2004; 42:432-8. [PMID: 15083103 DOI: 10.1097/01.mlr.0000124246.86156.54] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The number of for-profit hospices increased nearly 4-fold over the past decade, more than 6 times the growth of nonprofit hospices. Despite this growth, the impact of ownership on hospice care is largely unknown. We sought to assess differences in the provision of services to patients of for-profit and nonprofit hospices. METHODS Using the 1998 National Home and Hospice Care Survey, we examined services used by patients (N = 2080) cared for by 422 hospices nationwide. We used multivariable ordered logistic and logistic regression to assess the effect of profit status on service use, adjusting for potentially confounding patient and organizational characteristics. We calculated point estimates adjusted for sampling weights and standard errors adjusted for the clustering of patients within hospices. RESULTS In ordered logistic models controlling for organizational and patient factors, patients of for-profit hospices received a significantly narrower range of services (adjusted odds ratio [OR], 0.45; 95% confidence interval [CI], 0.22-0.92) than patients of nonprofit hospices. This result is driven by patients of for-profit hospices receiving significantly fewer types of hospice services that federal regulations term "noncore" or more discretionary services (adjusted OR, 0.34; 95% CI, 0.15-0.75). CONCLUSION The pattern of care differs in for-profit and nonprofit hospices. As the industry develops a substantial for-profit presence, it is critical for clinicians and other healthcare professionals to be alert to the potential impact of profit status on the care their patients receive.
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Affiliation(s)
- Melissa D A Carlson
- Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, Connecticut, USA
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Abstract
This study further examines whether not-for-profit hospitals exert pressure on for-profit hospitals to provide charity care and whether for-profit hospitals react differently than not-for-profit hospitals to managed care pressures and hospital competition in providing charity care. A two equation model is estimated using 1996 data from California hospitals. The results indicate that in mixed ownership markets, for-profit hospitals provide significantly less charity care as not-for-profit hospitals in the market provide more. Unexpectedly, study for-profit hospitals were not more influenced by price competition than other hospitals with respect to charity care. Having a unique role in providing charity care may justify continuing tax exemption for not-for-profit hospitals and enhance interest in payment and other policies with regard to conversions to ensure that not-for-profit hospitals continue to be represented in market areas.
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Khoury AJ, Weisman CS, Jarjoura CM. Ownership type and community benefits of women's health centers. Med Care Res Rev 2001; 58:76-99. [PMID: 11236234 DOI: 10.1177/107755870105800105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An important aspect of the changing health care system is the growth of women's health centers--organizations that design and deliver services to women. This growth has generated interest in the behavior of centers, especially because of increasing awareness of women's health issues. Using data from the 1994 National Survey of Women's Health Centers, the authors examined the association between ownership of centers and 12 measures of community benefits, and 296 nonprofit and 108 for-profit centers were compared. Overall, the nonprofits performed better than the for-profits in terms of serving underserved women, delivering comprehensive primary care services, providing training for health professionals and education services for clients and the community, and involving the community in center governance. Among women's health centers, the results show that ownership matters, and indicate the importance of supporting providers who serve the underserved and developing a standard of community benefits.
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Baker CM, Messmer PL, Gyurko CC, Domagala SE, Conly FM, Eads TS, Harshman KS, Layne MK. Hospital ownership, performance, and outcomes: assessing the state-of-the-science. J Nurs Adm 2000; 30:227-40. [PMID: 10823176 DOI: 10.1097/00005110-200005000-00004] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study 1) identified the research evidence; 2) assessed the state-of-the-science surrounding hospital ownership, performance, and outcomes in acute care hospitals in the United States; and 3) identified measurable components of hospital performance and outcomes for the organization, patient, and community. BACKGROUND As the size of the nonprofit sector decreases and the size of the for-profit sector increases, hospital ownership warrants examination. Most research has focused on either ownership and performance or ownership and outcomes, rather than the potential interaction of all three variables. METHODS A comprehensive, computerized search of the healthcare research literature yielded 69 data-based references published between 1985 and 1999. Coding sheets were developed to abstract the articles. Analysis involved synthesizing the research evidence for each of the three major variables and their components. RESULTS Hospital ownership has an impact on hospital performance in relation to system operations; costs, prices, and financial management practices; and personnel issues. Organizational outcomes are similar among hospital ownership types in relation to increasing administrative costs and overall mediocre efficiency. Organizational outcomes differ among hospital ownership types in relation to nursing staff mix and professional satisfaction. The association of hospital ownership with patient outcomes varies depending on the dimension measured. The evidence is mixed or inconclusive regarding hospital ownership and access to care, morbidity, and mortality. The association of hospital ownership and adverse events is consistently supported. Hospital ownership status has an impact on the type and magnitude of community benefits. Differences among the three hospital ownership types are minimized in a competitive market. CONCLUSIONS This study reinforces the position that nurse researchers need to include hospital ownership as an important structural variable in their studies of hospital-based nursing. Examining the conceptual links between ownership, performance, and outcomes requires the integration of macro-level and micro-level theory.
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Affiliation(s)
- C M Baker
- Indiana University School of Nursing, Indianapolis, USA.
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Scheffler RM. Managed behavioral health care and supply-side economics. 1998 Carl Taube Lecture. THE JOURNAL OF MENTAL HEALTH POLICY AND ECONOMICS 1999; 2:21-28. [PMID: 11967404 DOI: 10.1002/(sici)1099-176x(199903)2:1<21::aid-mhp33>3.0.co;2-o] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/1998] [Accepted: 12/20/1998] [Indexed: 11/12/2022]
Abstract
BACKGROUND: Within the past decade, the mental health care system in the United States has undergone a significant transformation in terms of delivery, financing and work force configuration. Contracting between managed care organizations (MCOs) and providers has become increasingly prevalent, paralleling the trend in health care in general. These managed care carve-outs in behavioral health depend on networks of providers who agree to capitated rates or discounted fees for service for those patients covered by the carve-out contracts. Moreover, the carve-outs use a broader array of mental health providers than is typically found in traditional indemnity plans, encourage time-limited versus long-term treatments and favor providers who are engaged in outpatient care. This phenomenal growth in managed behavioral health care over the past decade includes the rapid growth and quick consolidation of mental health MCOs. The period 1992-1998 shows steady and substantial annual increases in the number of enrollees in mental health MCOs, the figure more than doubling from 78.1 million people in 1992 to a projected 156.6 million in 1998, or 70% of insured lives. Moreover, these vast numbers of enrollees are becoming increasingly consolidated into a smaller number of firms. In 1997, 12 companies controlled nearly 85% of the managed behavioral health care market, with 60% of the market held by the three largest firms. STUDY AIMS: This article reviews empirical data and draws policy implications from the literature on managed behavioral health care in the United States. Starting with spending and spending trend estimates that show the average annual growth rate of mental health expenditures to be lower than that of health care expenditures in general over the past decade, the author examines utilization and price factors that may account for managed-care-induced cost reductions in behavioral health care, with special attention to hospital use patterns, fee discounting and the supply and earnings patterns of various types of mental health provider. In addition, data on staffing ratios and provider mixes of health maintenance organizations and mental health MCOs are reviewed as they reveal at least part of the dynamics of reconfiguration of the mental health work force in this era of managed care. CONCLUSIONS: As measured by changes in utilization and price, widespread application of "classic" managed care techniques such as preadmission review (gatekeeping), concurrent review, case management, standardized clinical guidelines and protocols, volume purchase of services and fee discounting appears to have led to significant cost reductions for providers of both impatient and outpatient mental health services. However, amidst a complex flux of market variables such as risk shifting, changing financial incentives and intensity of competition, not all of the reduction or slowdown in spending can be clearly and purely attributed to managed care. The data on the ongoing reconfiguration of the mental health work force are clearer in their implications: with an oversupply of all types of mental health providers, managed care has significant potential to increase the incidence of provider substitutions and spur the growth of integrated group practices. IMPLICATIONS FOR FURTHER RESEARCH: The current body of empirical and policy literature in mental health economics suggests several salient areas of follow-up. Is the proportionately greater impact of managed care on the annual growth rate of mental health care spending a temporary phenomenon or does it signal an enduring difference in the rates of increase between behavioral health care and health care in general? Beyond industry downsizing, what are the substitutions among mental health providers that are going on, and will go on, to produce cost-effective practices? What are the new financial or risk-sharing arrangements between providers and MCOs that will produce appropriate and high-quality mental health services?
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Affiliation(s)
- Richard M. Scheffler
- School of Public Health, 405 Warren Hall, University of California-Berkeley, Berkeley, CA 94720-7360, USA
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Schlesinger M, Gray B. A broader vision for managed care, Part 1: Measuring the benefit to communities. Health Aff (Millwood) 1998; 17:152-68. [PMID: 9637972 DOI: 10.1377/hlthaff.17.3.152] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
For the past quarter-century managed care plans have been judged almost exclusively in terms of their influence on the health and health care of individual enrollees. However, policymakers are now paying attention to the ways in which health care organizations affect the broader well-being of their communities. These forms of "community benefit" emerged originally from legal criteria for tax exemption but are increasingly applied to all health care organizations, whatever their form of ownership. In this paper we identify different paradigms for defining community benefit and trace the factors that have encouraged or discouraged their application to health care. We suggest several strategies encouraging managed care plans to broaden their goals to include community benefit.
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