Religious Hospital Monopolies.

This Viewpoint discusses challenges posed by religious hospital monopolies for patients who do not share the same faith.

St. Michael's Improvement Program - A Collaborative Approach to Sustainable Cost Savings.

In response to a challenging financial environment and increasing patient demand, St. Michael's Hospital needed to find long-term sustainable solutions to continue to provide high-quality patient care and invest in key priorities. By conducting Operational Reviews in focused areas, the hospital achieved $7.4 million of in-year savings in the first year, found standardizations, process efficiencies and direct cost savings that positioned itself for success in future funding models. Initiatives were grounded in evidence and relied heavily on the effective execution by the leadership, front-line staff and physicians. As organizations face similar challenges, this journey can provide key learnings.

'Big Fish to Fry' Quest for Major Donors.

I met him in the lobby of a large hotel in the Midwest as we were waiting for the doors to open to a panel discussion of health care experts. I noticed his name tag and recognized his Catholic health care system immediately. We had a common network. I introduced myself and discovered he was the system's chief financial officer. We were having a pleasant chat when I asked him about his system's foundation.

Circumventing 'free care' and 'shouting louder': using a health systems approach to study eye health system sustainability in government and mission facilities of north-west Tanzania.

BACKGROUND: Little is known about the contributions of faith-based organisations (FBOs) to health systems in Africa. In the specialist area of eye health, international and domestic Christian FBOs have been important contributors as service providers and donors, but they are also commonly critiqued as having developed eye health systems parallel to government structures which are unsustainable. METHODS: In this study, we use a health systems approach (quarterly interviews, a participatory sustainability analysis exercise and a social network analysis) to describe the strategies used by eye care practitioners in four hospitals of north-west Tanzania to navigate the government, church mission and donor rules that govern eye services delivery there. RESULTS: Practitioners in this region felt eye care was systemically neglected by government and therefore was 'all under the NGOs', but support from international donors was also precarious. Practitioners therefore adopted four main strategies to improve the sustainability of their services: (1) maintain 'sustainability funds' to retain financial autonomy over income; (2) avoid granting government user fee exemptions to elderly patients who are the majority of service users; (3) expand or contract outreach services as financial circumstances change; and (4) access peer support for problem-solving and advocacy. Mission-based eye teams had greater freedom to increase their income from user fees by not implementing government policies for 'free care'. Teams in all hospitals, however, found similar strategies to manage their programmes even when their management structures were unique, suggesting the importance of informal rules shared through a peer network in governing eye care in this pluralistic health system. CONCLUSIONS: Health systems research can generate new evidence on the social dynamics that cross public and private sectors within a local health system. In this area of Tanzania, Christian FBOs' investments are important, not only in terms of the population health outcomes achieved by teams they support, but also in the diversity of organisational models they contribute to in the wider eye health system, which facilitates innovation.

Costs of eye care services: prospective study from a faith-based hospital in Zambia.

PURPOSE: To estimate the mean costs of cataract surgery and refractive error correction at a faith-based eye hospital in Zambia. METHODS: Out-of-pocket expenses for user fees, drugs and transport were collected from 90 patient interviews; 47 received cataract surgery and 43 refractive error correction. Overhead and diagnosis-specific costs were determined from micro-costing of the hospital. Costs per patient were calculated as the sum of out-of-pocket expenses and hospital costs, excluding user fees to avoid double counting. RESULTS: From the perspective of the hospital, overhead costs amounted to US$31 per consultation and diagnosis-specific costs were US$57 for cataract surgery and US$36 for refractive error correction. When including out-of-pocket expenses, mean total costs amounted to US$128 (95% confidence interval [CI] US$96--168) per cataract surgery and US$86 (95% CI US$67--118) per refractive error correction. Costs of providing services corresponded well with the user fee levels established by the hospital. CONCLUSION: This is the first paper to report on the costs of eye care services in an African setting. The methods used could be replicated in other countries and for other types of visual impairments. These estimates are crucial for determining resources needed to meet global goals for elimination of avoidable blindness.

Catholic identity and charity care in the era of health reform.

Catholic healthcare institutions live amidst tension between three intersecting primary values, namely, a commitment of service to the poor and vulnerable, promoting the common good for all, and financially sustainability. Within this tension, the question sometimes arises as to whether it is ever justifiable, i.e., consistent with Catholic identity, to place limits on charity care. In this article we will argue that the health reform measures of the Affordable Care Act do not eliminate this tension but actually increase the urgency of addressing it. Moreover, we will conclude that the question of limiting charity care in a manner that is consistent with the obligations of Catholic identity around serving the poor and vulnerable, promoting the common good, and remaining financially sustainable is not a question of if, but of how such limits are established. Such limits, however, cannot be established in light of one overriding moral consideration or principle, but must be established in light of a multitude of principles guiding us to a holistic understanding of the interrelatedness of the moral dimensions of Catholic identity.

Provision of community benefits by tax-exempt U.S. hospitals.

BACKGROUND: The Patient Protection and Affordable Care Act (ACA) requires tax-exempt hospitals to conduct assessments of community needs and address identified needs. Most tax-exempt hospitals will need to meet this requirement by the end of 2013. METHODS: We conducted a national study of the level and pattern of community benefits that tax-exempt hospitals provide. The study comprised more than 1800 tax-exempt hospitals, approximately two thirds of all such institutions. We used reports that hospitals filed with the Internal Revenue Service for fiscal year 2009 that provide expenditures for seven types of community benefits. We combined these reports with other data to examine whether institutional, community, and market characteristics are associated with the provision of community benefits by hospitals. RESULTS: Tax-exempt hospitals spent 7.5% of their operating expenses on community benefits during fiscal year 2009. More than 85% of these expenditures were devoted to charity care and other patient care services. Of the remaining community-benefit expenditures, approximately 5% were devoted to community health improvements that hospitals undertook directly. The rest went to education in health professions, research, and contributions to community groups. The level of benefits provided varied widely among the hospitals (hospitals in the top decile devoted approximately 20% of operating expenses to community benefits; hospitals in the bottom decile devoted approximately 1%). This variation was not accounted for by indicators of community need. CONCLUSIONS: In 2009, tax-exempt hospitals varied markedly in the level of community benefits provided, with most of their benefit-related expenditures allocated to patient care services. Little was spent on community health improvement.

Population health management: a "start small" strategy.

Catholic Health Initiatives (CHI) is piloting population health management for a test population that comprises CHI employees and their families. CHI is using a medical home model to coordinate care. The system anticipates a reduction in its employee healthcare costs of 10 to 14 percent.

[The Hospital of Holy Spirit in Saxia of Rome during the XIII century examples for the study of an economic power's development]. / L'ospedale di Santo Spirito in Saxia di Roma nel duecento: esempi per lo studio dello sviluppo di una potenza economica.

The author analyzes the development of the Holy Spirit hospital's economic power during the XIII century through some illustrative examples of original parchment documents, pontifical and private. After the hospital was founded by the pope Innocentius III and gifted of many properties, its charitable activity attracted the admiration and respect of many people, who, with donations and testamentary dispositions, not only around Rome, but also in several Italian regions and outside Italy, contributed to make it ever more powerful in an economic sense.