Health Care Organizations Research Paper

Third, it pertains to a legal characteristic of organizations that is defined under the law of the jurisdiction in which they exist. In the USA, health care organizations are typically incorporated under state laws. Variations among these state laws are not important for our purposes, but the fact that fundamental aspects of the ownership and control of health care organizations (as well as the roles they play in the health care system) are defined by the laws and traditions that are specific to particular countries is. A recent effort to measure and compare the size of the nonprofit sectors in different countries had to define ‘nonprofits’ in terms of certain organizational characteristics (not profit-distributing, self-governing, voluntary) rather than legal form, because nations do not make the same legal distinctions between private and governmental or between for-profit and nonprofit (Salamon et al. 1999). To cite an example from health care, ownership by identifiable individuals is incompatible with the nonprofit form under US law, while Japan, where most hospitals are owned by physicians, is often said to prohibit for-profit ownership of hospitals because of a prohibition of ownership by corporations that pay dividends (Rodwin and Okamoto 2000).

Fourth, this research paper pertains primarily to types of health care organizations in which a mix of for-profit and nonprofit ownership is found. Thus, attention will not be directed to organizations that manufacture pharmaceuticals or hospital supplies (which are typically all for-profit corporations), to physicians’ practices (which are seldom incorporated as nonprofit organizations), or to charitable fundraising organizations (such as the American Cancer Society or the Royal Commonwealth Society for the Blind), which are all nonprofit. Our focus is on the types of organizations among which both for-profits and nonprofits can be found, as is the case with hospitals, nursing homes, health maintenance organizations, and home care agencies in the USA.

Most literature on for-profit and nonprofit health care comes from the USA, which has an unusually pluralistic health care system on both the provider and purchaser sides (Starr 1982). Although the health care systems of other countries are much more typified by governmental or quasigovernmental ownership, the private ownership of important components, such as hospitals, is not peculiar to the USA. In some countries there are doctor-owned clinics, small hospitals, or nursing facilities that are outgrowths or extensions of private physicians’ offices. Some countries that have universal health insurance systems nonetheless have private hospitals. These countries may either prohibit for-profit ownership, as does Canada, or they may exclude private hospitals (including for-profits) from participation in the national health insurance system, while permitting for-profit hospitals to serve people who have the desire and wealth to opt out of that system. Several investor-owned hospital companies from the USA also own hospitals in other countries, serving such niches. And at least one German hospital company owns some US hospitals. In recent years, American companies have begun to export versions of managed care to other countries, notably in Latin America (Stocker et al. 1999).

In the main, however, in Western countries other than the USA for-profit organizations that provide health services are extensions of doctors’ practices or constitute a sector that serves a small market outside of the governmental health system (and is often not included in statistical information about that system). This, plus the nation-specific nature of the laws that define the legal form of health care organizations, probably explains the paucity of research comparing for-profit nonprofit organizations in countries other than the USA or making cross-national comparisons of ownership forms. Policy debates about privatization have stimulated research on public versus private provision of services in a number of countries, but these are outside the scope of this research paper.

1. The Nonprofit For-Profit Distinction

In this research paper, the terms ‘for-profit’ and ‘nonprofit’ (or its less economical synonym, ‘not-for-profit’) are used as they are commonly defined under state statutes and federal tax law in the USA. The term ‘nonprofit’ invites confusion, since nonprofit organizations are not forbidden from generating surpluses of revenues over expenses. Indeed, such surpluses, which are called profits in the for-profit world, are essential to economic health and survival of nonprofit organizations. It is important, therefore, to be clear about the shared characteristics of for-profit and nonprofit organizations and the ways that they differ.

Table 1 shows that there are important similarities and differences between for-profit and nonprofit health care organizations in the USA (Gray 1992). Two key families of legally defined characteristics are particularly important in distinguishing these organizations. The first pertains to ownership, governance, and purpose. For-profit organizations have owners (proprietors, partners, or the shareholders of corporations), who share in the profits and increases (or decreases) in the value of the enterprise and who, in the corporate form, elect the board of directors. Those who operate the for-profit organization are thus either owners or are managers who are directly accountable to owners. Thus, those who control the organization have a direct stake in the financial performance of the organization.

By contrast, nonprofit organizations do not have owners (except insofar as they are subsidiaries of other nonprofit organizations) and are legally prohibited from distributing surplus revenues to those who control the organization—a characteristic that Hansmann (1980) called the nondistribution constraint. Nonprofit organizations are governed by boards of trustees whose members are typically chosen by the existing board and who are responsible for assuring that the organization operates soundly and adheres to the mission (charitable, educational, religious, etc.) for which it was chartered. Importantly, the boards to which management is accountable have no direct stake in the profitability of the institution.

The second family of differences pertains to the tax treatment of for-profit and nonprofit organizations (Simon 1987). Nonprofit organizations that meet qualifying standards have a variety of tax-related benefits under federal, state, and local laws. The tax treatment of nonprofits varies according to the kind of organization it is (for example, there are differences in how churches, grant making foundations, charitable organizations, and professional associations are treated) and according to governmental jurisdiction (criteria for exemption from local property taxes may differ from criteria for exemption from federal corporate income tax). However, most nonprofit health care organizations are exempt as charities from federal corporate income tax under Section 501(c)(3) of the Internal Revenue Service Code. Charity in this case is defined in terms of benefiting the community at large, not in terms of providing free care (Fox and Schaffer 1991). (Some health maintenance organizations and insurers are exempt under Section 501(c) (4) as social welfare organizations and receive less-favorable tax treatment than do the charitable organizations.) Other tax benefits also apply to organizations that are exempt in the eyes of the Internal Revenue Service. Charitable nonprofits are generally able to receive contributions that are tax deductible to the donor, to borrow at favorable rates under bond issues whose interest is not taxable to the lender, and to be exempt from local and state property taxes and certain excise taxes.

However, in health care there are important financial similarities between for-profits and nonprofits. First, the revenues of both for-profit and nonprofit health care organizations come overwhelmingly from the sale of services. For most nonprofit health care organizations, charitable contributions represent no more than one percent of revenues. To survive, these nonprofit organizations must compete successfully for business in a very crowded and heavily regulated marketplace. Though not businesses, they must operate in a very businesslike fashion.

Second, although nonprofit hospitals and HMOs have benefited in earlier periods from governmental grant and lending programs, today’s nonprofits and for-profits depend upon similar sources of capital— primarily retained earnings and debt (Institute of Medicine 1986). Thus, just as with for-profit organizations, the primary capital sources on which nonprofit health care organizations depend are a function of the organization’s economic performance. The fact that the typical nonprofit health care organization is tax exempt as a charitable organization under the Internal Revenue Service code suggests that they are subject to complex and somewhat conflicting social expectations.

Notwithstanding the importance of their common reliance on retained earnings and debt, for-profit and nonprofit organizations each have access to unique sources of capital. Unlike nonprofits, for-profits have the paid-in equity capital of individual and organizational investors or stockholders. Access to equity capital provides a substantial advantage during periods of growth, particularly for publicly traded firms whose stock price in relationship to earnings may be very high. The unique form of capital to which nonprofits have access is charitable contributions, as well as debt financing from instruments whose interest payments are not taxable for the lender.

These differences in sources of capital are enormously important regarding the expectations placed on these organizations—with stockholders seeking value, economic returns, and capital growth, and contributors seeking charitable behavior. The two families of differences have driven theoretical and empirical work in the social sciences (Powell 1987, Powell and Clemens 1998) and stimulated an array of public policy debates.

2. The Role And Performance Of Nonprofit Organizations

The question of why some segments of our capitalist economy are predominantly for-profit while others are predominantly nonprofit has intrigued social theorists and economists, who generally start with the premise that the incentives internal to the for-profit structure create a drive toward efficiency. So, what is the role of nonprofits? Several answers have been offered. Weisbrod (1990) suggests that nonprofits occupy a niche created by, on the one hand, the failure of for-profit organizations to provide services that benefit the community at large, not just the purchasers, and, on the other hand, the failure of governmental programs to meet the demand for other than average services. Hansmann (1980) posits that the nonprofit form provides a comparatively efficient alternative in situations of contract failure in which purchasers are not well situated to monitor the performance of sellers of services. The nondistribution constraint makes nonprofits less likely than for-profits to exploit the purchaser’s vulnerability. For services to be financed by donations, the nonprofit form gives potential donors some confidence that their funds will be used for the promised purpose (e.g., for charitable services). For services that are difficult for purchasers to monitor (and medical care is an example), the nonprofit form may provide some assurance that vulnerabilities of patients and payers will not be exploited.

Such theories suggest three directions in assessing the performance of nonprofit organizations—their costliness (in the absence of accountability to owners, are they less efficient?), their charitability (very important for tax-exempt organizations in a health care system with more than 40 million uninsured patients), and their effectiveness or trustworthiness as providers of services/care. The empirical literature that has attempted to assess these topics in different types of health care organization is large, growing, and impossible to summarize adequately in a brief article. Citations to most studies can be found, however, in the Institute of Medicine (1986) report on for-profit and a 1999 literature review that is available on-line (Gray et al. 1999) and that summarizes some 75 studies.

First, in health care, for-profit organizations are not necessarily less costly to purchasers than are nonprofits. Most studies of hospitals have found that costs to purchasers are higher in for-profits (Gray et al. 1999). This appears to be a response to ‘reimbursement maximization’ strategies based on exploiting the weaknesses of third-party payment systems, not to some inherent inefficiency disadvantage of for-profits vis-a-vis nonprofits. For example, several studies have shown that expenses incurred in the production of hospital services are similar in for-profit and nonprofit hospitals, but that markups of price over expenses are higher in for-profits.

Second, taken as a group, nonprofits are more likely to engage in charitable activities and public goods than are for-profits (Gray 1992, Claxton et al. 1997, Gray et al. 1999). For example, nonprofits care for more uninsured patients (Frank et al. 1990), provide more uncompensated care (Lewin et al. 1988), provide more services focused on vulnerable populations (LeBlanc and Hurley 1995, Shortell et al. 1987), and engage in education and research (Institute of Medicine 1986), and they are less likely to discourage admission of uninsured patients (Schlesinger et al. 1987) and less likely to avoid location in areas with large numbers of the uninsured (Norton and Staiger 1994). However, the charitable performance of nonprofits is quite variable, with charitable activities and public goods heavily concentrated in urban teaching hospitals. The performance of nonprofit hospitals as charitable organizations has come under criticism in recent decades, and in the 1990s eight US states established requirements for nonprofit hospitals to report on their community benefit activities. There is evidence that the charitable performance of nonprofits is enhanced by articulated community expectations and active public oversight (Schlesinger 1998).

Third, although the Institute of Medicine (1986) study found no clear pattern of ownership-related quality differences among hospitals, several more recent studies have found a quality advantage for nonprofits regarding hospital mortality (Hartz 1989, Kuhn et al. 1994, Sloan et al. 2000) and post-hospital recovery (Sloan et al. 2000). Quality advantages have been reported among nonprofit nursing homes (Hawes and Phillips 1986) and HMOs (Himmelstein et al 1999), two fields characterized by serious contractfailure problems. In nursing homes, many residents are unable to look after their own best interests and have no one else to do so and so must rely on their notoriously difficult-to-monitor relationship with the facility to protect their interests. In HMOs, the complexity of the incentive relationship between health plans and physicians may make it difficult for patients to be certain that contracted-for services are actually being provided.

At a more general level, the research findings to date suggest that for-profits are indeed more responsive to economic incentives than are nonprofits, which can be a problem in a field with significant information asymmetries between sellers and purchasers of service (Arrow 1963). In view of the similarities of for-profits and nonprofits in revenue capital and revenue sources and the regulatory regimes under which they must operate, the overall pattern of performance differences that are often small but generally in the predicted direction is notable. It is clear that the comparative performance of nonprofits and for-profits is not a simple function of ownership form, but of an interaction of ownership form with market forces, payment systems, and regulatory environments.

3. Ownership Trends In Health Care

The concentration of different forms of ownership varies in the USA across fields (nursing homes are predominantly for-profit; hospitals are mostly nonprofit) and over time (Marmor et al. 1987, Gray 1999). Among acute care community hospitals, surveys conducted early in the twentieth century reported that about half of all hospitals were for-profit (Stevens 1989, Starr 1982). The for-profit share of hospitals declined through the century, falling to 15 percent in 1965, with nonprofits comprising 60 percent and the remainder governmental—a level that has remained roughly the same, with a slight increase in for-profit and a slight decrease in governmental. However, the character of the for-profits has changed since the mid-1960s, with ownership by large, powerful, publicly traded investor-owned firms replacing ownership by local entrepreneurs (often doctors) as the predominant for-profit form, and with the average for-profit facility being larger as measured by the number of beds.

There are, however, a number of signs that the US health care system is moving toward an increased for-profit character. Even among hospitals, where the nonprofit share has been stable at 60 percent for 30 years, a shift toward for-profit has occurred beneath the surface. First, if beds rather than hospitals is used as the measure, the for-profit share of acute-care hospitals doubled between the mid-1960s and the mid- 1990s (from 6 percent to 12 percent, largely at the expense of public hospitals). Second, even with hospitals as the unit of analysis, if one includes nonprofit and public hospitals that are managed by for-profit firms, as well as non-acute care hospitals (e.g., psychiatric and rehabilitation facilities), the for-profit sector among hospitals grew to about 25 percent of the total by the late 1990s.

Great increases in for-profit ownership have occurred elsewhere in the US health care system since the 1980s, as is shown in Table 2. Health maintenance organizations (HMOs), which were almost exclusively nonprofit in 1980, are now predominantly for-profit (Gray 1999). Strong trends in the for-profit direction also occurred among home health agencies and dialysis treatment centers. Within the trend toward forprofit ownership has been a second trend—ownership not by individual proprietors but by investor-owned corporations that own multiple units (Institute of Medicine 1986, Corrigan et al. 1997). Similar trends toward multi-institutional arrangements have also occurred among nonprofits. This, along with increased entrepreneurial activity by nonprofits (Sloan 1998) has led to concerns among many observers that the character of many nonprofit health care organizations has changed in ways that mirror the for-profits.

Comparing the cases of community hospitals and HMOs, some of the factors that are involved in the persistence and change in ownership patterns among health care organizations can be seen (Gray 1999). On the side of persistence, many nonprofit hospitals, with their multiple important community roles (care giver, employer) and their governing boards often made up of prominent citizens, have received both charitable and governmental support in bad economic times. The difficulty of closing a nonprofit hospital has been frequently noted in health policy circles as hospital occupancy has declined since the 1980s. Nonprofits have also engaged in a variety of strategies to compete and grow—entering into multihospital systems, merging, joint-venturing, and establishing for-profit subsidiaries. Use of these strategies has carried a price, however. The increased commercialism of the nonprofits has attracted criticism and fanned doubts about their deservedness of tax exemption.

The most important factor affecting the ownership composition of the health care field is public policy. It could hardly be otherwise since the basic corporate structures of for-profit and nonprofit organizations are themselves products of public policy. But the role that public policy plays in influencing the composition and performance of health care organizations has become increasingly apparent since the 1950s. The creation and growth of the investor-owned hospital industry was a direct result of capital reimbursement policies built into the Medicare legislation in 1965 (Gray 1992). The interest costs incurred in borrowing money to purchase hospitals was a reimbursable expense under Medicare, and gave purchasers annual payments for the noncash expense called depreciation. Since Medicare payments to hospitals were based on reimbursing them for costs incurred, the legislation also provided for giving for-profit hospitals generous ‘return-on-equity’ payments so that investors would receive a return on their investments. All of these provisions stimulated the growth of the investor owned companies into the early 1980s, when, in separate actions, Congress reduced return-on-equity payments and changed the depreciation rules so that Medicare would pay for the depreciation of any particular asset only once. After these changes were made, the leading investor-owned companies all stopped growing at a time in which it was being predicted that they were going to take over the system.

Similarly, the growth of the nonprofit HMO industry in the 1970s and the for-profit transformation of the field in the 1980s were direct results of public policy. First, provisions of the HMO Act of 1973 made capital available to nonprofit HMOs. But the field was transformed in the for-profit direction in the 1980s as a result of the Reagan administration’s decision to phase out the HMO Act’s support of nonprofit HMOs and to undertake a program to stimulate investment in for-profit HMO companies, which had not previously existed; a surge in demand for managed care from the corporate sector which was experiencing large increases in health care costs; and inattentive state regulators who allowed many nonprofit HMOs to be acquired for a pittance by their leadership and converted into for-profit organizations (Gray 1999).

Permissive state regulation also created the environment for a surge in the acquisition of nonprofit hospitals by large investor-owned firms (Columbia HCA, Tenet) in the early and mid-1990s (Gray 1997). This, along with conversions involving HMOs and state Blue Cross insurance companies, led more than 25 states to pass legislation in the late 1990s to regulate nonprofit conversions. Some 120 new foundations were created in the 1980s and 1990s from the proceeds of the sale of nonprofit health care organizations (Isaacs et al. 1997). Studies of the consequences of hospital conversions have generally shown them to have occurred among financially troubled institutions and that few negative consequences could be documented, either because the institutions had previously engaged in only low levels of charitable activity or because strong contractual protections had been built into the sales agreement (Mark 1999, Young and Desai 1999). Interestingly, there have also been examples of for-profit hospitals that reverted to the control of nonprofit organizations, though the trend remains in the direction of greater for profits.

4. Conclusion

The American health care experience has shown that for-profits and nonprofits can coexist in the same field. It has also shown that the comparative performance of the two forms of organizations are influenced by contextual factors such as the incentive structures built into the systems by which they are paid, regulatory regimes, professional values, and public expectations. Although for-profits generally appear to be more responsive to economic incentives than are nonprofits, nonprofits cannot be indifferent to economic realities. It is increasingly apparent that policymakers need to pay attention to the characteristics of the organizations that provide health services as they design programs, payment systems, and regulatory structures to achieve desired health policy goals.

The US experience also shows that the for-profit nonprofit composition of fields can change, sometimes quite rapidly, as can the ownership form of particular organizations. In a policy-sensitive field such as health care, the future of for-profit and nonprofit health care organizations is likely to be affected quite substantially by public policies. These policies may be focused specifically on some aspect of the ownership issue, but the most important ones may have an ownership neutral motivation, such as the desire to control costs in large governmental programs. For segments of the health care industry in which government is the dominant payer, it may be difficult for investor-owned companies to generate revenues in the long run that will be satisfactory to investors. High profitability is likely to lead to cuts in the programs that fund that profitability. For-profits also face suspicion that has been driven by highly publicized fraud-related scandals involving some leading health care companies, plus widespread distrust of the predominantly forprofit HMO industry.

For their part, nonprofits face a twin challenge. In a highly competitive health care system dominated by large purchasers and without direct governmental subsidies, they must perform well enough economically to be able to continue paying their bills and to maintain their access to capital, which depends upon lenders’ confidence in their ability to repay their debts. As they do this, they must also contend with a growing skepticism, fed in part by their own economically driven policies and practices, regarding whether they engage in sufficient charitable activity to deserve the tax-related benefits they receive.

With health care accounting for almost 15 percent of the US economy, investor money is likely to be available to fund new ideas for making money from the provision of health services, and there is interest among American companies in making investments in other countries as well. The clear advantages that the for-profit form might offer are the ability to raise capital, a willingness to take risks and innovate, and, perhaps, a reservoir of experience that might be transferable into new contexts. But will countries that have had little experience with this organizational form in their health care system find such factors outweigh possible costs in terms of a changed ethos of the health care system, major shifts in power and control, and potential serious problems of exploitation of the informational asymmetries that typify health care?

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