New insights about community benefit evaluation: Using the Community Health Implementation Evaluation Framework to assess what hospitals are measuring.

BACKGROUND: Nonprofit hospitals are required to conduct community health needs assessments (CHNA) every 3 years and develop corresponding implementation plans. Implemented strategies must address the identified community needs and be evaluated for impact. PURPOSE: Using the Community Health Implementation Evaluation Framework (CHIEF), we assessed whether and how nonprofit hospitals are evaluating the impact of their CHNA-informed community benefit initiatives. METHODOLOGY: We conducted a content analysis of 83 hospital CHNAs that reported evaluation outcomes drawn from a previously identified 20% random sample ( n = 613) of nonprofit hospitals in the United States. Through qualitative review guided by the CHIEF, we identified and categorized the most common evaluation outcomes reported. RESULTS: A total of 485 strategies were identified from the 83 hospitals' CHNAs. Evaluated strategies most frequently targeted behavioral health ( n = 124, 26%), access ( n = 83, 17%), and obesity/nutrition/inactivity ( n = 68, 14%). The most common type of evaluation outcomes reported by CHIEF category included system utilization ( n = 342, 71%), system implementation ( n = 170, 35%), project management ( n = 164, 34%), and social outcomes ( n = 163, 34%). PRACTICE IMPLICATIONS: CHNA evaluation strategies focus on utilization (the number of individuals served), with few focusing on social or health outcomes. This represents a missed opportunity to (a) assess the social and health impacts across individual strategies and (b) provide insight that can be used to inform the allocation of limited resources to maximize the impact of community benefit strategies.

Threatening Nonprofit Hospital Tax Exemption: A Better Path Forward.

This Viewpoint discusses regulation of nonprofit hospitals in a way that will advance their charitable purposes without eliminating their tax exemption status.

Nonprofit Hospitals: Profits And Cash Reserves Grow, Charity Care Does Not.

Using the National Academy of State Health Policy Hospital Cost Tool, we compared changes in hospital profits with changes in hospitals' charity care and cash reserves between 2012 and 2019. We estimated substantial growth in nonprofit hospital operating profits and cash reserves in this period but no corresponding increase in charity care.

Provision of Social Care Services by US Hospitals.

Policy Points Hospitals address population health needs and patients' social determinants of health by offering social care services. Tax-exempt hospitals are required to invest in community benefits, including social care services programs, though most community benefits spending is toward unreimbursed health care services. Tax-exempt hospitals offer about 36% more social care services than for-profit hospitals. Among tax-exempt hospitals, those that allocate more resources to community benefits spending offer more types of social care services, but those in states with minimum community benefits spending requirements offer fewer social care services. Policymakers may consider specifically incentivizing community benefits expenditures toward particular social care services, including linking tax exemptions to implementation, utilization, and outcome targets, to more directly help patients. CONTEXT: Despite growing interest in identifying patients' social needs, little is known about hospitals' provision of services to address them. We identify social care services offered by US hospitals and determine whether hospital spending or state policies toward community benefits are associated with the provision of these services by tax-exempt hospitals. METHODS: National secondary data about hospitals were collected from the American Hospital Association Annual Survey, with additional Internal Revenue Service (IRS) Form 990 data on community benefits spending from CommunityBenefitInsight.org and state-level community benefits policies from HilltopInstitute.org. Descriptive statistics for types of social care services and hospital characteristics were calculated, with bivariate chi-square and t-tests comparing for-profit and tax-exempt hospitals. Multivariable Poisson regression was used to estimate associations between hospital characteristics and types of services offered and among tax-exempt hospitals to estimate associations between social care services and community benefits spending and policies. Multivariable logistic regressions modeled associations between community benefits spending/policies and each type of social care services. FINDINGS: Private US hospitals offered an average of 5.7 types of social care services in 2018. Tax-exempt hospitals offered about 36% more social care services than for-profit hospitals. Larger number of beds, health system affiliation, and having community partnerships are associated with more social care services, whereas rural hospitals and those managed under contract offered fewer social care services. Among tax-exempt hospitals, greater community benefits spending is associated with offering more total (incidence rate ratio [IRR] = 1.10, p < 0.01) and patient-focused social care services (IRR = 1.16, p < 0.01). Hospitals in states with minimum community benefits spending requirements offered significantly fewer social care services. CONCLUSIONS: Although tax-exempt status and increased community benefits spending were associated with increased social care services provision, the observation that certain hospital characteristics and state minimum community benefits spending requirements were associated with fewer social care services suggests opportunities for policy reform to increase social care services implementation.

Relative Productivity of For-Profit Hospitals: A Big or a Little Deal?

This study asks: Does the empirical evidence support the conclusion that for-profit (FP) hospitals are more productive or efficient than private not-for-profit (NFP) hospitals or non-federal public (PUB) hospitals? Alternative theories of NFP behavior are described. Our review of individual empirical hospital studies of quality, service mix, community benefit, and cost/efficiency in the United States published since 2000 indicates that no systematic difference exists in cost/efficiency, provision of uncompensated care, and quality of care. But FPs are more likely to provide profitable services, higher service intensity, have lower shares of uninsured and Medicaid patients, and are more responsive to external financial incentives. That FP hospitals are not more efficient runs counter to property rights theory, but their relative responsiveness to financial incentives supports it. There is little evidence that FP market presence changes NFP behaviors. Observed differences between FP and NFP hospitals are mostly a "little deal."

Influence of Not-for-Profit Hospital Ownership Type on Community Benefit and Charity Care.

Non-profit hospitals are expected to provide charity care and other community benefits to adjust their tax exemption status. Using the Medicare Hospital Cost Report, American Hospital Association Annual Survey, and the American Community Survey datasets, we examined if church-affiliated hospitals spent more on charity care and community benefit. For this analysis, we defined five main categories of community benefits were measured: total community benefit; charity care; Medicaid shortfall; unreimbursed other means-tested services; and the total of unreimbursed education and unfunded research. Multiple regression was used to examine the effect of church ownership, controlling for other factors, on the level of community benefit in 2644 general acute care non-profit hospitals. Descriptive analyses and multiple regression were used to show the relationship between the provision of community benefits and church affiliation including Catholic (CH), other church-affiliated hospitals (OCAH), and non-church affiliated hospitals (NCAH). The non-profit hospital on average spent 6.5% of its total expenses on community benefits. NCAH spent 6.09%, CH spent 7.5%, and OCAH spent 9.4%. Non-profits spent 2.8% of their total expenses on charity care, with the highest charity care spending for OCAH (5.2%), followed by CH (3.9%), and NCAH (2.4%). Regression results showed that CH and OCAH, on average, spent 1.08% and 2.16% more on community benefits than NCAHs. In addition, CH and OCAH spent more on other categories of community benefits except for education and research. Church-affiliated hospitals spend more on community benefits and charity care than non-church affiliated nonprofit hospitals.

Proadi-SUS: analysis of financial resources in the three-year periods 2009-2011, 2012-2014 and 2015-2017 / Proadi-SUS: análise dos recursos financeiros nos triênios 2009-2011, 2012-2014 e 2015-2017

ABSTRACT OBJECTIVE To characterize the tax exemption resources used in the Support Program for Institutional Development of the Unified Health System (Proadi-SUS) in the 3-year periods 2009-2011, 2012-2014, 2015-2017, considering the total volume of resources linked to the debate on tax expenditures on health and the constitution of a "new form of philanthropy" in the sector. METHODS To understand the philanthropic sector, tax expenditures between 2001 and 2017 were analyzed. To evaluate the resources used in the program, the values of projects and areas of activity were examined. RESULTS A real increase in the values of general tax expenses and tax expenses referring to the philanthropic sector was found. There was also a real increase in the program's resources. A total of 407 projects were carried out, amounting to R$ 3.4 billion for the period. An analysis of the average value of the projects shows an increase in values for all hospitals included in the program, with the exception of one of the institutions. In the 2009-2011 and 2012-2014 periods, the area with the highest number of projects and the most resources was "Management techniques and operation in health services". In the 3-year period 2015-2017, however, the sector that received the most investments and the largest number of projects developed was "Human Resources Training". CONCLUSION The program characterizes a different expression of the public-private partnership in the health sector linked to the principles of the new public management. As a development for future investigations, a qualitative characterization of the projects developed and the actions' impact on the public sector demands is necessary.

RESUMO OBJETIVO Caracterizar os recursos de isenção fiscal usufruídos no Programa de Apoio ao Desenvolvimento Institucional do Sistema Único de Saúde (Proadi-SUS) nos triênios 2009-2011, 2012-2014, 2015-2017, considerando o volume total dos recursos atrelado ao debate dos gastos tributários em saúde e a constituição de uma "nova modalidade de filantropia" no setor. MÉTODOS Para compreender o setor filantrópico, analisaram-se os gastos tributários no período de 2001 e 2017. Para avaliar os recursos utilizados no programa, foram examinados os valores dos projetos e das áreas de atuação. RESULTADOS Foi constatado um crescimento real dos valores dos gastos tributários gerais e dos gastos tributários referentes ao setor filantrópico. Constatou-se, também, um aumento real dos recursos do programa. Foram realizados 407 projetos, totalizando um valor de R$ 3,4 bilhões para o período. Ao se analisar o valor médio dos projetos, explicita-se ampliação dos valores para todos os hospitais inseridos no programa, com exceção de uma das instituições. Nos triênios 2009-2011 e 2012-2014, a área de atuação com maior número de projetos e mais recursos foi a "Área de técnicas e operação de gestão em serviços de saúde". Já no triênio 2015-2017, o setor que contou com mais investimentos e maior número de projetos desenvolvidos foi o de "Capacitação de recursos humanos". CONCLUSÃO O programa caracteriza outro patamar na relação do setor público com o setor privado/empresariado da saúde, atrelado aos princípios da nova gestão pública. Faz-se necessária, como desdobramento para futuras investigações, uma caracterização qualitativa dos projetos desenvolvidos e do impacto das ações diante das demandas do setor público.

What do nonprofit hospitals reward? An examination of CEO compensation in nonprofit hospitals.

Nonprofit hospital chief executive officer (CEO) compensation has received considerable attention in light of nonprofits' tax-favored status as well as the high costs of hospital care. Past studies have found that hospital financial performance is a significant determinant of CEO pay but nonprofit performance, including quality and charity care, are not. Using post-ACA data, we re-examine whether a variety of hospital performance measures are important determinants of nonprofit hospital CEO compensation. We found mixed evidence with respect to the significance of the association between financial performance and uncompensated care and CEO compensation. Among the other nonprofit performance measures, patient satisfaction was significantly associated with CEO compensation, but other measures were not significant determinants of CEO compensation. Our results suggest nonprofit hospitals balance their financial health against their mission when setting CEO incentives. Additional policy targeting transparency in hospital CEO compensation may be warranted to help policymakers understand the specific factors used by hospital boards to incentivize CEOs.

Hospital Service Offerings Still Differ Substantially By Ownership Type.

Nonprofit, for-profit, and government hospitals are all more likely to offer services when they are relatively profitable than when they are relatively unprofitable. However, for-profit hospitals are considerably more likely than others to provide services based on profitability. After hospital and market characteristics are adjusted for, nonprofit hospitals offer relatively unprofitable services more than for-profit hospitals and less than government hospitals. Profitable services typically exhibit the opposite pattern. For-profit hospitals are also more likely to adopt or discontinue services consistent with changes in service profitability than are nonprofits, which in turn are more likely to do so than government hospitals. These results are similar to those we found before passage of the Affordable Care Act, when many more patients were uninsured. Policy makers and researchers tend to focus on whether nonprofit hospitals provide sufficient free care to justify tax benefits, thereby overlooking the significance of ownership for service provision, which likely has critical health and spending consequences.

Comparing the value of community benefit and Tax-Exemption in non-profit hospitals.

OBJECTIVE: We examined the characteristics of non-profit hospitals providing more community benefits and charity care than value of their tax exemptions and how this relationship changed between 2011 and 2018. DATA SOURCES: Primary dataset was schedule H Form IRS 990 data. This data was merged with the American Hospital Association, Medicare Hospital Cost Report, and the America Community Survey. STUDY DESIGN: We measured six categories of tax benefits and 17 types of community benefits. Subtracting the average value of community benefits provided by for-profit hospitals, we computed incremental community benefit and charity care provided by each non-profit hospital. EXTRACTION METHODS: A nationally representative sample was created of 11 776 non-profit hospital-year observations from 1472 unique hospitals over the 2011 to 2018 period was created. Descriptive analyses and random effect logistic regression were used to show associations between hospital characteristics and difference between incremental net community benefits and the value of tax-exemption. PRINCIPAL FINDINGS: After adjusting for community benefits provided by for-profits hospitals, on average, non-profit hospitals spent 5.9% (CI: 5.8%-6.0%) of their total expenses on community benefits; 1.3% (CI: 1.2%-1.3%) on charity care; and received 4.3% (CI: 4.2%-4.4%) of total expenses in tax exemptions. A total of 38.5% of non-profit hospitals did not provide more community benefit and 86% did not provide more charity care than the value of their tax exemption. Hospitals with fewer beds, providing residency education and located in high poverty communities were more likely to provide more incremental community benefits and charity care than the value of their tax exemption, while system affiliation had a negative association. CONCLUSION: The amount of community benefits and charity care provided by non-profits varied substantially across non-profit hospitals. Establishing minimum requirements for non-profit hospitals or publicly ranking hospitals based on their community benefit or charity care contributions, could encourage greater community benefits and charity care.

Gender differences in paediatric hospital chief executive officer compensation.

Though there is a well-established gender pay gap in medicine, studies on compensation disparities between women and men chief executive officers (CEO) showed mixed results. We conducted a cross-sectional study of children's hospitals in the USA to evaluate whether CEO gender was associated with compensation differences. Nine out of 31 children's hospitals employed a female CEO. There was no significant difference between men and women CEOs in terms of hospital characteristics (location, size or ranking in US News and World report) or CEO characteristics (advanced degrees, tenure or compensation). Gender was not associated with significant differences in CEO compensation.

For-profit hospitals as anchor institutions in the United States: a study of organizational stability.

BACKGROUND: Anchor institutions, by definition, have a long-term presence within their local communities, but it is uncertain as to whether for-profit hospitals meet this definition; most research on anchor institutions to date has been limited to nonprofit organizations such as hospitals and universities. Accordingly, this study aims to determine whether for-profit hospitals are stable enough to fulfill the role of anchor institutions through a long-term presence in communities which may help to stabilize local economies. METHODS: This longitudinal study analyzes national, secondary data between 2008 and 2017 compiled from the Dartmouth Atlas of Health Care, the American Hospital Association Annual Survey, and County Health Rankings. We use descriptive statistics to calculate the number of closures and mergers of hospitals of different ownership type, as well as staffing levels. Using logistic regression, we also assessed whether for-profit hospitals had higher odds of closing and merging, controlling for both organization and community factors. RESULTS: We found for-profit hospitals to be less stable than their public and nonprofit hospital counterparts, experiencing disproportionately more closures and mergers over time, with a multivariable analysis indicating a statistically significant difference. Furthermore, for-profit hospitals have fewer full-time employees relative to their size than hospitals of other ownership types, as well as lower total payroll expenditures. CONCLUSIONS: Study findings suggest that for-profit hospitals operate more efficiently in terms of expenses, but this also may translate into a lower level of economic contributions to the surrounding community through employment and purchasing initiatives. For-profit hospitals may also not have the stability required to serve as long-standing anchor institutions. Future studies should consider whether for-profit hospitals make other types of community investments to offset these deficits and whether policy changes can be employed to encourage anchor activities from local businesses such as hospitals.

Estresse emocional entre cuidadores informais de pacientes em cuidados paliativos / Estrés emocional entre los cuidadores informales de pacientes en cuidados paliativos / Emotional stress between informal caregivers of patients in palliative care

RESUMO Objetivo analisar o estresse emocional de cuidadores informais de pacientes em Cuidados Paliativos. Método pesquisa de campo, exploratória, com abordagem qualitativa, realizada com 10 cuidadores informais de um hospital filantrópico em João Pessoa, Paraíba, Brasil. Os dados foram coletados entre abril e maio de 2021, mediante questionário online e entrevista semiestruturada virtual, e então, submetidos à análise de conteúdo temática, após aprovação do Comitê de Ética em Pesquisa com Seres Humanos. Resultados foram obtidas as categorias temáticas: Cansaço físico e emocional do cuidador informal; Cuidado como forma de dever e retribuição do afeto; O cuidado e a necessidade de rede de apoio social e da espiritualidade; Dificuldades na adaptação do cuidador aos Cuidados Paliativos na instituição hospitalar. Considerações finais é necessária a divisão das responsabilidades do cuidado entre cuidadores informais e outros familiares. Salienta-se a importância da equipe de saúde estimular a dimensão espiritual e social do cuidador.

RESUMEN Objetivo analizar el estrés emocional de cuidadores informales de pacientes en Cuidados Paliativos. Método investigación de campo, exploratoria, con enfoque cualitativo, realizada junto a 10 cuidadores informales de un hospital filantrópico en João Pessoa, Paraíba, Brasil. Los datos se recogieron entre abril y mayo de 2021, mediante un cuestionario online y una entrevista semiestructurada virtual, y luego se sometieron a un análisis de contenido temático, tras la aprobación del Comité de Ética en Investigación con Seres Humanos. Resultados Se obtuvieron las siguientes categorías temáticas: Fatiga física y emocional del cuidador informal; Cuidado como forma de deber y retribución del afecto; El cuidado y la necesidad de red de apoyo social y espiritualidad; Dificultades de adaptación del cuidador a los Cuidados Paliativos en la institución hospitalaria. Consideraciones finales es necesario repartir las responsabilidades de los cuidados entre los cuidadores informales y otros miembros de la familia. Así mismo, se destaca la importancia de que el equipo de salud estimule la dimensión espiritual y social del cuidador.

ABSTRACT Objective to analyze emotional stress among informal caregivers of patients in palliative care. Method this exploratory, qualitative field study was conducted with 10 informal caregivers from a philanthropic hospital in João Pessoa, Paraíba, Brazil. Data were collected between April and May 2021, through online questionnaire and virtual semi-structured interview, and then submitted to thematic content analysis, after approval by the human research ethics committee. Results the thematic categories obtained were: physical and emotional fatigue in the informal caregiver; care as a form of duty and retribution for affection; care and the need for a social support network and spirituality; and caregivers' difficulties in adapting to palliative care in the hospital. Final considerations care responsibilities must be divided among informal and family caregivers. Also stressed is the importance of the health team's stimulating caregivers spiritually and socially.

Hospital Ownership and Financial Stability: A Matched Case Comparison of a Nonprofit Health System and a Private Equity-Owned Health System.

The long-term financial stability of hospital systems represents a "grand challenge" in health care. New ownership forms, such as private equity (PE), promise to achieve better financial performance than nonprofit or for-profit systems. In this study, we compare two systems with many similarities, but radically different ownership structures, missions, governance, and merger and acquisition (M&A) strategies. Both were nonprofit, religious systems serving low-income communities - Montefiore Health System and Caritas Christi Health Care. Montefiore's M&A strategy was to invest in local hospitals and create an integrated regional system, increasing revenues by adding primary doctors and community hospitals as feeders into the system and achieving efficiencies through effective resource allocation across specialized units. Slow and steady timing of acquisitions allowed for organizational learning and balancing of debt and equity. By 2019, it owned 11 hospitals with 40,000 employees and had strong positive financials and low reliance on debt. By contrast, in 2010, PE firm Cerberus Capital bought out Caritas (renamed Steward Health Care System) and took control of the Board of Directors, who set the system's strategic direction. Cerberus used Steward as a platform for a massive debt-driven acquisition strategy. In 2016, it sold off most of its hospitals' property for $1.25 billion, leaving hospitals saddled with long-term inflated leases; paid itself almost $500 million in dividends; and used the rest for leveraged buyouts of 27 hospitals in 9 states in 3 years. The rapid, scattershot M&A strategy was designed to create a large corporation that could be sold off in five years for financial gain - not for health care integration. Its debt load exploded, and by 2019, its financials were deeply in the red. Its Massachusetts hospitals were the worst financial performers of any system in the state. Cerberus exited Steward in 2020 in a deal that left its physicians, the new owners, holding the debt.

No mission? No motivation. On hospitals' organizational form and charity care provision.

A healthcare provider faces two decision problems. On the one hand, it chooses its organizational form: a hospital can be a for-profit institution providing compensated care only, or it can be a nonprofit organization whose mission is enhancing access to care for uninsured, low-income patients. On the other hand, the provider chooses which health professionals to hire, without observing their heterogeneous skills and their pro-social motivation. These decisions are related because an increase in the percentage of revenues, that the nonprofit hospital sacrifices for charity care, might enhance the motivation of its workers and induce some of them to donate their labor, that is, to volunteer. Accordingly, this article analyzes the provider's optimal screening contracts, which are contingent on workers' ability and satisfy limited liability, and relates them to the optimal choice of its mission-orientation. The results provide a new rationale for: a the emergence of different organizational forms for hospitals, such as for-profits and nonprofits, which complement public hospitals in the provision of health care, b the heterogeneity in the degree of charity care chosen by different nonprofit hospitals.

Nursing organisation during COVID-19: experiences of an unaided, not-for-profit quaternary care teaching hospital in India.

India reported its index case of coronavirus disease 2019 (COVID-19) in January 2020 and since then there has been an alarming rise in cases. In response to the worsening pandemic and the challenge presented by COVID-19 for hospitals in the public sector, the Government of India asked the country's private hospitals to reserve a percentage of their beds for COVID-19 patients. This article describes how nursing services at the Christian Medical College, Vellore - an unaided, not-for-profit quaternary care teaching hospital in Tamil Nadu, India - addressed various challenges to ensure a sustained, high-quality nursing care response to increased patient load. The main challenges included changing COVID-19 policies, ensuring the hospital was prepared to care for COVID-19 patients, and ensuring the availability of nurses. The article demonstrates how proactive planning, empowered involvement of nursing leaders and collaborative efforts resulted in deployment and training of 1,400 nurses, and ensured coordinated care for more than 10,000 patients with COVID-19.

Charity Care and Community Benefit in Non-Profit Hospitals: Definition and Requirements.

Policymakers are using different ways to measure the community benefit provided by non-profit hospitals because different policy makers have different policy objectives. We compare 3 commonly used measures of community benefit; examine the correlation across the 3 measures; examine how the distribution of community benefits varies across non-profit hospitals; and compare the factors associated with the level of community benefit for each definition. The main dataset for this study is the Schedule H of IRS Form 990 data for 2017. We merged this data with the 2017 American Hospital Association (AHA), the 2017 CMS Hospital Cost Report, and the 2018 American Community Survey data. The final sample consists of 1904 non-profit hospitals. We define 3 measures of community benefit: (1) Total community benefits: combining all 17 possible measures in the 990 data; (2) Total community benefits less unreimbursed Medicaid care because it reflects a policy choice made by the state; and (3) only charity care. We also subdivided the community benefits into individual and service-based benefit. Gini Coefficients and descriptive analysis show the distribution of 3 types of community benefit measures. On average, hospitals spent 8.1% of their expenses on all community benefits; 4.3% on community benefits less unreimbursed Medicaid; and 1.7% on charity care. The provision of charity care showed more variation (Gini coefficient) than the other 2 measures. Different hospital and geographic characteristics were associated with each definition, suggesting that different types of hospitals place emphasis on different community benefits. When policy makers choose among different definitions of community benefit, they should consider what incentives they want to instill.

Assessment of Overuse of Medical Tests and Treatments at US Hospitals Using Medicare Claims.

Importance: Overuse of health care services exposes patients to unnecessary risk of harm and costs. Distinguishing patterns of overuse among hospitals requires hospital-level measures across multiple services. Objective: To describe characteristics of hospitals associated with overuse of health care services in the US. Design, Setting, and Participants: This retrospective cross-sectional analysis used Medicare fee-for-service claims data for beneficiaries older than 65 years from January 1, 2015, to December 31, 2017, with a lookback of 1 year. Inpatient and outpatient services were included, and services offered at specialty and federal hospitals were excluded. Patients were from hospitals with the capacity (based on a claims filter developed for this study) to perform at least 7 of 12 investigated services. Statistical analyses were performed from July 1, 2020, to December 20, 2020. Main Outcomes and Measures: Outcomes of interest were a composite overuse score ranging from 0 (no overuse of services) to 1 (relatively high overuse of services) and characteristics of hospitals clustered by overuse rates. Twelve published low-value service algorithms were applied to the data to find overuse rates for each hospital, normalized and aggregated to a composite score and then compared across 6 hospital characteristics using multivariable regression. A k-means cluster analysis was used on normalized overuse rates to identify hospital clusters. Results: The primary analysis was performed on 2415 cohort A hospitals (ie, hospitals with capacity for 7 or more services), which included 1 263 592 patients (mean [SD] age, 72.4 [14] years; 678 549 women [53.7%]; 101 017 191 White patients [80.5%]). Head imaging for syncope was the highest-volume low-value service (377 745 patients [29.9%]), followed by coronary artery stenting for stable coronary disease (199 579 [15.8%]). The mean (SD) composite overuse score was 0.40 (0.10) points. Southern hospitals had a higher mean score than midwestern (difference in means: 0.06 [95% CI, 0.05-0.07] points; P < .001), northeast (0.08 [95% CI, 0.06-0.09] points; P < .001), and western hospitals (0.08 [95% CI, 0.07-0.10] points; P < .001). Nonprofit hospitals had a lower adjusted mean score than for-profit hospitals (-0.03 [95% CI, -0.04 to -0.02] points; P < .001). Major teaching hospitals had significantly lower adjusted mean overuse scores vs minor teaching hospitals (difference in means, -0.07 [95% CI, -0.08 to -0.06] points; P < .001) and nonteaching hospitals (-0.10 [95% CI, -0.12 to -0.09] points; P < .001). Of the 4 clusters identified, 1 was characterized by its low counts of overuse in all services except for spinal fusion; the majority of major teaching hospitals were in this cluster (164 of 223 major teaching hospitals [73.5%]). Conclusions and Relevance: This cross-sectional study used a novel measurement of hospital-associated overuse; results showed that the highest scores in this Medicare population were associated with nonteaching and for-profit hospitals, particularly in the South.