Comparison of the Financial and Operational Characteristics of For-Profit and Nonprofit Hospitals Receiving Federal Graduate Medical Education Payments, 2011-2020.

This study compares graduate medical education (GME) payments between nonprofit and for-profit hospitals between 2011 and 2020 to assess how hospitals value GME.

Association Between Dialysis Facility Ownership and Access to the Waiting List and Transplant in Pediatric Patients With End-stage Kidney Disease in the US.

Importance: Care of adults at profit vs nonprofit dialysis facilities has been associated with lower access to transplant. Whether profit status is associated with transplant access for pediatric patients with end-stage kidney disease is unknown. Objective: To determine whether profit status of dialysis facilities is associated with placement on the kidney transplant waiting list or receipt of kidney transplant among pediatric patients receiving maintenance dialysis. Design, Setting, and Participants: This retrospective cohort study reviewed the US Renal Data System records of 13 333 patients younger than 18 years who started dialysis from 2000 through 2018 in US dialysis facilities (followed up through June 30, 2019). Exposures: Time-updated profit status of dialysis facilities. Main Outcomes and Measures: Cox models, adjusted for clinical and demographic factors, were used to examine time to wait-listing and receipt of kidney transplant by profit status of dialysis facilities. Results: A total of 13 333 pediatric patients who started receiving maintenance dialysis were included in the analysis (median age, 12 years [IQR, 3-15 years]; 6054 females [45%]; 3321 non-Hispanic Black patients [25%]; 3695 Hispanic patients [28%]). During a median follow-up of 0.87 years (IQR, 0.39-1.85 years), the incidence of wait-listing was lower at profit facilities than at nonprofit facilities, 36.2 vs 49.8 per 100 person-years, respectively (absolute risk difference, -13.6 (95% CI, -15.4 to -11.8 per 100 person-years; adjusted hazard ratio [HR] for wait-listing at profit vs nonprofit facilities, 0.79; 95% CI, 0.75-0.83). During a median follow-up of 1.52 years (IQR, 0.75-2.87 years), the incidence of kidney transplant (living or deceased donor) was also lower at profit facilities than at nonprofit facilities, 21.5 vs 31.3 per 100 person-years, respectively; absolute risk difference, -9.8 (95% CI, -10.9 to -8.6 per 100 person-years) adjusted HR for kidney transplant at profit vs nonprofit facilities, 0.71 (95% CI, 0.67-0.74). Conclusions and Relevance: Among a cohort of pediatric patients receiving dialysis in the US from 2000 through 2018, profit facility status was associated with longer time to wait-listing and longer time to kidney transplant.

Structural Inequities, HIV Community-Based Organizations, and the End of the HIV Epidemic.

Community-based organizations (CBOs) are integral to achieving the goal of Ending the HIV epidemic (EHE). Their familiarity with and proximity to communities position them to effectively implement strategies necessary to address determinants of health through their formal and informal medical and social services. However, structural inequities have contributed to the demise of many organizations that were instrumental in early responses to the HIV epidemic. We define structural inequities for HIV CBOs as systems in which policies, institutional practices, organizational (mis)representations, and other norms work to produce and maintain inequities that affect CBOs' ability to survive and thrive. In this discussion, we describe the organizational threats to grassroots HIV CBOs and the risks to livelihood and longevity, including examples. The invaluable role of HIV CBOs in EHE and their role in responding to existing and novel infectious diseases like COVID-19 should not be overlooked. Recommendations to promote structural equity are offered. (Am J Public Health. 2022;112(3):417-425. https://doi.org/10.2105/AJPH.2021.306688).

Philanthropy in Plastic Surgery: Best Practices and Measuring Impact.

BACKGROUND: Philanthropy in plastic surgery supports research, clinical care, academic infrastructure, and education in the United States and internationally. Plastic surgeons have opportunities to innovatively address unmet needs in their local and global communities by forming philanthropic nonprofit organizations. METHODS: The authors queried three national philanthropic databases (Charity Navigator, Guidestar, and ProPublica) for Internal Revenue Service 990 form tax return information related to philanthropic plastic surgery organizations. The authors analyzed the financial information publicly available about current plastic surgery philanthropic organizations and their funding sources. RESULTS: Seventy-three federally tax-exempt groups identified plastic surgery as their primary area of work to the Internal Revenue Service in 2019, and 52 of those organizations said they engaged in clinical and/or educational philanthropy.3 In 2017, a total of $158.5 million was donated to these groups in cash and noncash donations including equipment and time. Analyses of 6 years (2013 to 2018) of tax records from groups that provide plastic surgery clinical, research, or educational philanthropy reveal that government grants provide very little funding for this work. Eighty-six percent of money raised for these groups in 2017 was collected by means of direct donations. Money obtained from fundraising events contributed 2 percent to their total monies raised in 2017 on average and 8 percent came from noncash gifts. CONCLUSIONS: A broad body of academic research is reviewed here that guides best practices and measuring a group's impact and outcomes. The details of a philanthropic group's organization and finances directly influence the impact of their work and, as such, are worthy of our sustained attention.

National Psoriasis Foundation COVID-19 Task Force Guidance for Management of Psoriatic Disease During the Pandemic: Version 1.

OBJECTIVE: To provide guidance about management of psoriatic disease during the coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: A task force (TF) of 18 physician voting members with expertise in dermatology, rheumatology, epidemiology, infectious diseases, and critical care was convened. The TF was supplemented by nonvoting members, which included fellows and National Psoriasis Foundation (NPF) staff. Clinical questions relevant to the psoriatic disease community were informed by questions received by the NPF. A Delphi process was conducted. RESULTS: The TF approved 22 guidance statements. The average of the votes was within the category of agreement for all statements. All guidance statements proposed were recommended, 9 with high consensus and 13 with moderate consensus. LIMITATIONS: The evidence behind many guidance statements is limited in quality. CONCLUSION: These statements provide guidance for the management of patients with psoriatic disease on topics ranging from how the disease and its treatments impact COVID-19 risk and outcome, how medical care can be optimized during the pandemic, what patients should do to lower their risk of getting infected with severe acute respiratory syndrome coronavirus 2 and what they should do if they develop COVID-19. The guidance is intended to be a living document that will be updated by the TF as data emerge.

Efficiency and profitability in US not-for-profit hospitals.

This article examines the relationship between hospital profitability and efficiency. A cross-section of 1317 U.S. metropolitan, acute care, not-for-profit hospitals for the year 2015 was employed. We use a frontier method, stochastic frontier analysis, to estimate hospital efficiency. Total margin and operating margin were used as profit variables in OLS regressions that were corrected for heteroskedacity. In addition to estimated efficiency, control variables for internal and external correlates of profitability were included in the regression models. We found that more efficient hospitals were also more profitable. The results show a positive relationship between profitability and size, concentration of output, occupancy rate and membership in a multi-hospital system. An inverse relationship was found between profits and academic medical centers, average length of stay, location in a Medicaid expansion state, Medicaid and Medicare share of admissions, and unemployment rate. The results of a Hausman test indicates that efficiency is exogenous in the profit equations. The findings suggest that not-for-profit hospitals will be responsive to incentives for increasing efficiency and use market power to increase surplus to pursue their objectives.

Nonprofit Hospitals' Response to the Opioid Epidemic in Urban Communities: A Content Analysis of Hospitals' Community Health Needs Assessments and Implementation Strategies.

CONTEXT: Addressing the opioid epidemic requires a coordinated community response; yet, the role that nonprofit hospitals play in these efforts has not been systematically examined. OBJECTIVE: To explore hospital-initiated strategies to address opioid use in urban communities most affected by the opioid epidemic. DESIGN: We conducted content analysis of publicly available community health needs assessments (CHNAs) and accompanying implementation strategies of 140 nonprofit hospitals. We employed a qualitative approach using open coding methods to explore the extent to which hospitals identified opioid use as a community health need and engaged in interventions to address opioid use in their communities. We also conducted bivariate analysis to compare organizational and community characteristics of hospitals that did and did not engage in strategies to address opioid use. SETTING: One hundred forty nonprofit hospitals in urban areas with high opioid death rates across 25 states. RESULTS: Almost 70% of CHNAs identified opioid use as a community health need, and 63% of implementation strategies included at least 1 hospital-initiated activity to address this need. More than 90% of these implementation strategies involved providing additional capacity for and access to treatment. Bivariate analysis showed that hospitals that engaged in activities to address opioid use did not differ meaningfully from hospitals that did not engage in such activities, with 2 exceptions. Hospitals that relied on consultants to prepare the CHNA were more likely to engage in activities to address opioid use as were hospitals located in Medicaid expansion states. CONCLUSIONS: Nonprofit hospitals are taking action to address the opioid epidemic in their communities, most commonly by providing additional treatment capacity for patients with opioid use. While an important contribution, hospitals need incentives to develop a more comprehensive response to the opioid epidemic that extends beyond medical care to include the social and economic determinants of this crisis.

The Road to Nonprofit Diversity and Inclusion.

Leadership at the board and executive levels across the nonprofit sector remains predominantly composed of white individuals, despite an increasingly diverse society. Research documents distinct benefits associated with diversity and inclusion, but efforts to move the dial have fallen short. This article explores how voluntary associations can prioritize racial/ethnic equity in their governance and provides specific steps for the examination of culture, practices, and processes required to operationalize change. There are a variety of professional societies and associations, also known as business leagues, established under the Internal Revenue Code. To be exempt, these organizations must be devoted to improving an industry or profession, as distinguished from performing particular services for individuals, and when successful they serve to improve the economic and social well-being of the entire nation.

Micro-costing and a cost-consequence analysis of the 'Girls Active' programme: A cluster randomised controlled trial.

Physical inactivity has been identified as a leading risk factor for premature mortality globally, and adolescents, in particular, have low physical activity levels. Schools have been identified as a setting to tackle physical inactivity. Economic evidence of school-based physical activity programmes is limited, and the costs of these programmes are not always collected in full. This paper describes a micro-costing and cost-consequence analysis of the 'Girls Active' secondary school-based programme as part of a cluster randomised controlled trial (RCT). Micro-costing and cost-consequence analyses were conducted using bespoke cost diaries and questionnaires to collect programme delivery information. Outcomes for the cost-consequence analysis included health-related quality of life measured by the Child Health Utility-9D (CHU-9D), primary care General Practitioner (GP) and school-based (school nurse and school counsellor) service use as part of a cluster RCT of the 'Girls Active' programme. Overall, 1,752 secondary pupils were recruited and a complete case sample of 997 participants (Intervention n = 570, Control n = 427) was used for the cost-consequence analysis. The micro-costing analysis demonstrated that, depending upon how the programme was delivered, 'Girls Active' costs ranged from £1,054 (£2 per pupil, per school year) to £3,489 (£7 per pupil, per school year). The least costly option was to absorb 'Girls Active' strictly within curriculum hours. The analysis demonstrated no effect for the programme for the three main outcomes of interest (health-related quality of life, physical activity and service use).Micro-costing analyses demonstrated the costs of delivering the 'Girls Active' programme, addressing a gap in the United Kingdom (UK) literature regarding economic evidence from school-based physical activity programmes. This paper provides recommendations for those gathering cost and service use data in school settings to supplement validated and objective measures, furthering economic research in this field. Trial registration: -ISRCTN, ISRCTN10688342.

The Society of Vascular Surgery International Scholars Program: The First Decade.

OBJECTIVE: The Society for Vascular Surgery (SVS) is a not-for-profit medical society, whose goal is to further advance in vascular health on a global scale. With its 10th anniversary in sight, we were interested in analyzing the impact of a specific scholarship given under the SVS, the International Scholars Program. Our goal was to examine the awardees' characteristics and academic productivity. MATERIALS AND METHODS: We measured the number of peer-reviewed articles, before and after the program, using PubMed® and Google Scholar® (2008-2018) of the scholarship recipients. Editorials, book chapters, letter to editor, and oral/poster presentations were excluded. A survey was sent out to assess the awardees' current status. RESULTS: The average number of applicants/year was 15.4 (standard deviation ± 6.69), with 17.5% females and a mean age of 37 ± 3.37 years, with 5.6 ± 2.30 years status post vascular fellowship. Brazil had the highest number of recipients (n = 5; 18.5%) followed by China (n = 4; 14.8%). No significant difference was noted between each country in terms of publications (P = .45), nor with after the SVS scholarship program compared to before (P = .14, 1.84 vs 2.76). The survey concluded 33% had attended a subsequent SVS meeting after the program, with 27% having presented their research (n = 15). The recipients noted the program helped adopt new practices in clinical management (n = 13, 87%), learn new procedures (n = 10, 67%), gain local/regional leadership (n = 9, 60%), and improve technical skills (n = 8, 53%). The most visited clinical sites were Massachusetts General Hospital and Mayo Clinic (n = 4, 27%). The program was given a 9.1/10 rating. CONCLUSION: The program was successful in maintaining academic productivity by continuing to publish research even after the scholarship, while teaching recipients skills to further improve their career goals. The award remains a competitive process that selects highly skilled recipients and still has much growth and progress to look forward to over the next decade.

Why Don't Hospitals Prioritize Substance Abuse in Their Community Benefit Programming?

The goal of this study was to understand whether Appalachian Ohio hospitals prioritized substance abuse in their IRS-mandated community health needs assessments (CHNAs) and if not, what factors were important in this decision. Analysis of CHNA reports from all 28 hospitals in the region supplemented interview data from in-depth phone interviews, with 17 participants tasked with overseeing CHNAs at 21 hospitals. The CHNA reports show that hospitals in this region prioritize substance abuse and mental health less often than access to care and obesity. Interviews suggest 4 reasons: lack of resources, risk aversion, concern about hospital expertise, and stigma related to substance abuse. Hospitals are playing a larger role in public health as a result of CHNA requirements but resist taking on challenging problems such as substance abuse. The report concludes by summarizing concrete steps to ensure that community benefit efforts address pressing health problems. The implications of this study are manifest in concrete recommendations for encouraging hospitals to address pressing health problems in their community benefit efforts.

Trends in governance structure and activities among not-for-profit U.S. hospitals: 2009-2015.

BACKGROUND: In U.S. hospitals, boards of directors (BODs) have numerous governance responsibilities including overseeing hospital activities and guiding strategic decisions. BODs can help hospitals adapt to changes in their markets including those stemming from a shift from fee-for-service to value-based purchasing. The recent increase in market turbulence for hospitals has brought renewed attention to the work of BODs. PURPOSE: The aim of the study was to examine trends in hospital BOD structure and activities and determine whether these changes are commensurate with approaches designed to respond to market pressures. METHODOLOGY/APPROACH: We examined hospital level data from The Governance Institute Survey (2009, 2011, 2013, and 2015) and corresponding years of the American Hospital Association Annual Survey in a pooled, cross-sectional design. We conducted individual multivariate models with adjustments for hospital and market characteristics, comparing the changes in BOD structures, demographics, and activities over time. FINDINGS: The sample included 1,811 hospital-year observations, including 682 unique facilities. We found that BODs in 2015 had less internal management (ß = -2.25, p < .001) and fewer employed and nonemployed physicians (ß = -8.28, p < .001) involved on the BOD. Moreover, compared to 2009, racial and ethnic minorities (2013 ß = 2.88, p < .001) and women (2013 ß = 1.60, p = .045; 2015 ß = 2.06, p = .049) on BODs increased over time. In addition, BODs were significantly less likely to spend time on the following activities in 2015, as compared to 2009: discussing strategy and setting policy (ß = -5.46, p = .002); receiving reports from management, board committees, and subsidiaries (ß = -29.04, p < .001); and educating board members (ß = -4.21, p < .001). Finally, BODs had no changes in the type of committees reported over time. PRACTICE IMPLICATIONS: Our results indicate that hospital BODs deploy various strategies to adapt to current market trends. Hospital decision-makers should be aware of the potential effects of board structure on organization's position in the changing health care market.

Multitasking in Nursing Homes: Differences Between For-Profit and Nonprofit Quality Outcomes.

BACKGROUND AND OBJECTIVES: Nursing homes (NHs) in the United States face increasing pressures to admit Medicare postacute patients, given higher payments relative to Medicaid. Changes in the proportion of residents who are postacute may initiate shifts in care practices, resource allocations, and priorities. Our study sought to determine whether increases in Medicare short-stay census have an impact on quality of care for long-stay residents. RESEARCH DESIGN AND METHODS: This study used panel data (2005-2010) from publicly-available sources (Nursing Home Compare, Area Health Resource File, LTCFocus.org) to examine the relationship between a 1-year change in NH Medicare census and 14 measures of long-stay quality among NHs that experienced a meaningful increase in Medicare census during the study period (N = 7,932). We conducted analyses on the overall sample and stratified by for- and nonprofit ownership. RESULTS: Of the 14 long-stay quality measures examined, only one was shown to have a significant association with Medicare census: increased Medicare census was associated with improved performance on the proportion of residents with pressure ulcers. Stratified analyses showed increased Medicare census was associated with a significant decline in performance on 3 of 14 long-stay quality measures among nonprofit, but not for-profit, facilities. DISCUSSION AND IMPLICATIONS: Our findings suggest that most NHs that experience an increase in Medicare census maintain long-stay quality. However, this may be more difficult to do for some, particularly nonprofits. As pressure to focus on postacute care mount in the current payment innovation environment, our findings suggest that most NHs will be able to maintain stable quality.

Neoliberal Long-Term Care: From Community to Corporate Control.

Publicly (mainly Medicaid) funded long-term care (LTC) services have evolved from a nursing home dominated system of service to a much more balanced system including home- and community-based services (HCBS) programs over the last 30 years. The HCBS programs have been largely administered by the state and local level nonprofit aging networks (ANs) consisting of Area Agencies on Aging and thousands of service providers. Over the last decade, however, for-profit HMOs administered primarily by large insurance companies have begun to displace AN organizations. State policymakers have embraced for-profit privatizations under the rationale that this approach will generate greater savings, efficiencies, and higher quality outcomes than the traditional public or private nonprofit models of program administration. As we show here, there is very little evidence for this rationale; yet, this lack of evidence has not prevented the continuing growth of for-profit managed LTC programs supported more by an ideology of market fundamentalism than empirical evidence. We also describe six possible consequences of the trend toward corporate control of public LTC services in the years ahead.

Better together: Coexistence of for-profit and nonprofit firms with an application to the U.S. hospice industry.

Many markets maintain a nontrivial mix of both nonprofit and for-profit firms, particularly in health care industries such as hospice, nursing homes, and home health. What are the effects of coexistence vs. dominance of one ownership type? We show how the presence of both ownership types can lead to greater diversity in consumer types served, even if both firms merely profit-maximize. This is the case where firms serve consumers for multiple consumption durations, but where donations are part of a nonprofit firm objective function and happen after services have been provided. This finding is strengthened if the good or service has value beyond immediate consumption or the direct consumer. We show these predictions empirically in the hospice industry, using data containing over 90 percent of freestanding U.S. hospices, 2000-2008. Nonprofit and for-profit providers split the patient market according to length of stay, leading to a wider range of patients being served than in the absence of this coexistence.

Government resource contributions to the private-not-for-profit sector in Uganda: evolution, adaptations and implications for universal health coverage.

BACKGROUND: A case study was prepared examining government resource contributions (GRCs) to private-not-for-profit (PNFP) providers in Uganda. It focuses on Primary Health Care (PHC) grants to the largest non-profit provider network, the Uganda Catholic Medical Bureau (UCMB), from 1997 to 2015. The framework of complex adaptive systems was used to explain changes in resource contributions and the relationship between the Government and UCMB. METHODS: Documents and key informant interviews with the important actors provided the main sources of qualitative data. Trends for GRCs and service outputs for the study period were constructed from existing databases used to monitor service inputs and outputs. The case study's findings were validated during two meetings with a broad set of stakeholders. RESULTS: Three major phases were identified in the evolution of GRCs and the relationship between the Government and UCMB: 1) Initiation, 2) Rapid increase in GRCs, and 3) Declining GRCs. The main factors affecting the relationship's evolution were: 1) Financial deficits at PNFP facilities, 2) advocacy by PNFP network leaders, 3) changes in the government financial resource envelope, 4) variations in the "good will" of government actors, and 5) changes in donor funding modalities. Responses to the above dynamics included changes in user fees, operational costs of PNFPs, and government expectations of UCMB. Quantitative findings showed a progressive increase in service outputs despite the declining value of GRCs during the study period. CONCLUSIONS: GRCs in Uganda have evolved influenced by various factors and the complex interactions between government and PNFPs. The Universal Health Coverage (UHC) agenda should pay attention to these factors and their interactions when shaping how governments work with PNFPs to advance UHC. GRCs could be leveraged to mitigate the financial burden on communities served by PNFPs. Governments seeking to advance UHC goals should explore policies to expand GRCs and other modalities to subsidize the operational costs of PNFPs.

Towards universal health coverage: a mixed-method study mapping the development of the faith-based non-profit sector in the Ghanaian health system.

BACKGROUND: Faith-based non-profit (FBNP) providers have had a long-standing role as non-state, non-profit providers in the Ghanaian health system. They have historically been considered to be important in addressing the inequitable geographical distribution of health services and towards the achievement of universal health coverage (UHC), but in changing contexts, this contribution is being questioned. However, any assessment of contribution is hampered by the lack of basic information about their comparative presence and coverage in the Ghanaian health system. In response, since the 1950s, there have been repeated calls for the 'mapping' of faith-based health assets. METHODS: A historically-focused mixed-methods study was conducted, collecting qualitative and quantitative data and combining geospatial mapping with varied documentary resources (secondary and primary, current and archival). Geospatial maps were developed, providing a visual representation of changes in the spatial footprint of the Ghanaian FBNP health sector. RESULTS: The geospatial maps show that FBNPs were originally located in rural remote areas of the country but that this service footprint has evolved over time, in line with changing social, political and economic contexts. CONCLUSION: FBNPs have had a long-standing role in the provision of health services and remain a valuable asset within national health systems in Ghana and sub-Saharan Africa more broadly. Collaboration between the public sector and such non-state providers, drawing on the comparative strengths and resources of FBNPs and focusing on whole system strengthening, is essential for the achievement of UHC.