Hospital market structure and the behavior of not-for-profit hospitals

I exploit a change in hospital financial incentives to examine whether the behavior of private not-for-profit hospitals is systematically related to the share of nearby hospitals organized as for-profit firms. My findings demonstrate that not-for-profit hospitals in for-profit intensive areas are significantly more responsive to the change than their counterparts in areas served by few for-profit providers. Differences in financial constraints and other observable factors correlated with for-profit hospital penetration do not explain the heterogeneous response. The findings suggest that not-for-profit hospitals mimic the behavior of private for-profit providers when they actively compete with them.     

Competition among hospitals

We examine competition in the hospital industry, in particular the effect of ownership type (for-profit, not-for-profit, government). We estimate a structural model of demand and pricing in the hospital industry in California, then use the estimates to simulate the effect of a merger. California hospitals in 1995 face an average price elasticity of demand of -4.85. Not-for-profit hospitals face less elastic demand and act as if they have lower marginal costs. Their prices are lower than those of for-profits, but markups are higher. We simulate the effects of the 1997 merger of two hospital chains. In San Luis Obispo County, where the merger creates a near monopoly, prices rise by up to 53%, and the predicted price increase would not be substantially smaller were the chains not-for-profit.     

The U.S. Medicare Disproportionate Share Hospital program and capacity planning

U.S. Medicare's Disproportionate Share Hospital (DSH) program provides financial assistance to hospitals that serve low-income populations. Statutory formulas determine the DSH payments made to hospitals; however, the formulas applied to “large” urban hospitals (at least 100 beds) are more generous than those used for “small” urban hospitals (less than 100 beds). The purpose of this study is to determine if the DSH program's 100-bed threshold influences bed capacity planning. We find that the threshold drives a significant discontinuity in the distribution of urban hospital bed capacities, with hospitals tending to maintain just enough beds to qualify for higher DSH payments. The magnitude of the discontinuity is greatest in hospitals with strong incentives to manage bed capacity; and, compared to government and not-for-profit hospitals, for-profit hospitals are more likely to manage capacity to meet the 100-bed threshold. Our findings highlight the potential for regulatory institutions to have unintended influence on capacity planning decisions.     

Distortions in Capital Asset Acquisition and Financing under Cost-Based Reimbursement

The paper examines distortions in the acquisition and financing of capital assets under a cost-based reimbursement system within an adjusted present value (APV) framework. For a not-for-profit (NFP) vendor the acquisition, when internally financed, is typically a negative-NPV investment. But when financed through debt with reimbursed interest payments, the combined decision becomes worthwhile (positive APV). This can explain why NFP firms resort to substantial debt financing even though internal funds may be available and any tax benefits are absent. Policy implications and suggestions for improving unintended inequities in the system are also discussed.     

How hospital ownership affects access to care for the uninsured

This article addresses the effect of hospital ownership on the delivery of service to uninsured patients. It compares the volume of uninsured patients treated in for-profit and nonprofit hospitals by regarding hospital ownership and service as endogenous. Instrumental variable estimates are used to predict the percentage of patients who are uninsured, controlling for hospital ownership and service. The study shows that when for-profit and nonprofit hospitals are located in the same area, they serve an equivalent number of uninsured patients, but for-profit hospitals indirectly avoid the uninsured by locating more often in better-insured areas.     

Profit status of microfinance institutions and incentives for earnings management

We theorize that for-profit microfinance institutions (MFIs) have higher incentives to use earnings management techniques when compared to their not-for-profit counterparts. Indeed, we show empirically that, when facing a distress period, for-profit MFIs are more likely to recognize impairment loan loss provisions than not-for-profit ones in about 0.8% of assets. This is consistent with the notion that those institutions are employing “big bath” accounting practices. Finally, using the 2008 crisis as an exogenous shock and country-level recessions as an exogenous measure of distress, we replicate our results.     

The effects of hospital ownership on medical productivity

To develop new evidence on how hospital ownership and other aspects of hospital market composition affect health care productivity, we analyze longitudinal data on the medical expenditures and health outcomes of the vast majority of nonrural elderly Medicare beneficiaries hospitalized for new heart attacks over the period 1985-1996. We find that the effects of ownership status are quantitatively important. Areas with a presence of for-profit hospitals have approximately 2.4% lower levels of hospital expenditures, but virtually the same patient health outcomes. We conclude that for-profit hospitals have important spillover benefits for medical productivity.     

A comparison of hospital responses to reimbursement policies for Medicaid psychiatric patients.

Hospital expenditures continue to increase at rates that are higher than that of GNP growth. Policymakers are experimenting with a number of reimbursement methods in an attempt to curtail the growth in hospital costs. This article empirically assesses the impact of various hospital reimbursement methods on the use of hospital services. We specified and estimated a model of hospital duration for Medicaid psychiatric patients. A new semiparametric approach to estimation was implemented for a large national sample of hospital discharges. The empirical findings show significant reductions in hospital duration are associated with per case prospective payment as compared with cost-based reimbursement.     

An empirical examination of capital expenditure in the health sector

This empirical study in the nursing home industry attempts to delineate factors, and thus acquire insights, as to capital expenditures, and address a critical issue regarding governmental reimbursement policy and the economic viability of health care institutions. Combinations of financial performance, financial structure, and institutional context associated with high capital investment nursing homes differ from combinations associated with low capital investment homes. A multivariate analysis of data obtained from 185 nursing homes shows that although there was some difference between the two groups of nursing homes in basic financial and institutional characteristics, only a small subset of the variables were statistically significant discriminators. The hypothesis was then examined within each of the three major nursing home segments—for-profit, not-for-profit, and country homes. Neither financial performance, financial structure, nor institutional context alone is sufficient to explain differences in capital investment behavior. Perhaps more importantly, the extent to which these combination of factors do contribute to explaining capital investment strategies differs within each of the major segments of the industry. Also, these combinations of factors generally differ across the major industry segments as they relate to capital investment strategies.     

Are for-profit hospital conversions harmful to patients and to Medicare?

We examine how changes in hospital ownership to and from for-profit status affect quality and Medicare payments per hospital stay. We hypothesize that hospitals converting to for-profit ownership boost post acquisition profitability by reducing dimensions of quality not readily observed by patients and by raising prices. We find that 1-2 years after conversion to for-profit status, mortality of patients, which is difficult for outsiders to monitor, increases while hospital profitability rises markedly and staffing decreases. Thereafter, the decline in quality is much lower. A similar decline in quality is not observed after hospitals switch from for-profit to government or private nonprofit status.     

资本结构选择偏好、成长性与公司绩效

本文通过基于不同资本结构选择偏好和成长性分类对上市公司资本结构和绩效的关系进行研究,研究发现:我国上市公司资本结构与绩效整体呈负相关;考虑内生性基础上,资本结构对绩效的负面影响提高了;不同负债水平下,资本结构对绩效的影响存在显著差异,且负债水平越高,资本结构对公司绩效的影响越大;在不同成长性水平下,资本结构与绩效都是负相关的,且成长性越低负面影响越大。     

Internal Versus External Capital Markets in the Insurance Industry: The Role of Reinsurance

This study compares internal and external sources of capital in the insurance industry by analyzing reinsurance activity between affiliated and unaffiliated insurers. Tests are performed using data from a large sample of property-liability insurers that are affiliated with at least one other property-liability insurer. Results indicate that while demands for internal and external reinsurance have some factors in common, there are cost-based differences in internal and external capital, as well as structural differences in the use of internal and external reinsurance. Results are consistent with previous theories related to internal versus external capital markets.     

The Impact of Health Care Reform on Capital Acquisition for Hospitals

In this paper, the response of the market for hospital stocks to the episode of the Medicare Prospective Payment System (PPS) legislation and its resulting impact on the ability of hospitals to generate capital for expansion and growth are addressed. The response to PPS legislation is evaluated by examining stock returns of publicly traded hospital companies using both traditional event study analysis and intervention analysis. The paper focuses on the effect of PPS over time and uses qualitative data to support the empirical evidence. Before and after its passage, the market reacted negatively to PPS legislation. This result supports qualitative evidence showing that hospitals' capital positions were impaired. When profit margins fell, bond ratings went down, while borrowing costs increased; the rate of hospital bond defaults went up and capital improvements were delayed.     

Bank Capital Requirements, Capital Structure and Regulation

This paper studies the impact of capital requirements, deposit insurance and franchise value on a bank’s capital structure. We find that properly regulated banks voluntarily choose to maintain capital in excess of the minimum required. Central to this decision is both firm franchise value and the ability of regulators to place banks in receivership stripping equity holders of firm value. These features of our model help explain both the capital structure of the large mortgage Government Sponsored Enterprises and the recent increase in risk taking through leverage by financial institutions. The insights gained from the model are useful in guiding the discussion of financial regulatory reforms.     

Adverse Selection, Moral Hazard, and Outlier Payment Policy

In this article, we analyze the rationale for introducing outlier payments into a prospective payment system for hospitals under adverse selection and moral hazard. The payer has only two instruments: a fixed price for patients whose treatment cost is below a threshold     and a cost-sharing rule for outlier patients. We show that a fixed-price policy is optimal when the hospital is sufficiently benevolent. When the hospital is weakly benevolent, a mixed policy solving a trade-off between rent extraction, efficiency, and dumping deterrence must be preferred. We show how the optimal combination of fixed price and partially cost-based payment depends on the degree of benevolence of the hospital, the social cost of public funds, and the distribution of patients severity.     

THE EFFECTS OF ALTERNATIVE REIMBURSEMENT SYSTEMS ON THE OPERATING BEHAVIOUR OF NURSING HOMES

Nursing home care in Australia is provided by both for-profit and not-for-profit nursing homes. Operating expenditure in nursing homes is funded by the Commonwealth Government. The reimbursement system currently in operation is linked to ownership structure. This paper examines differences in operating behaviour as a result of a reimbursement system based on ownership structure. The results of this study indicate that differences in behaviour occur as a result of ownership differences, ineffective controls and the lack of incentives in the reimbursement system to operate efficiently. These differences have important implications for policy change affecting the funding of nursing home care.     

Instilling activism in trustees

One of the great challenges in America today is the stewardship of its not-for-profit institutions. While the profit motive may be absent in the running of such organizations, the demand for thoughtful budgeting, cost accounting, and financial skills still exists. Voluntary community hospitals in particular--given the economic realities of the day--need leadership, reciprocal education, and future planning. Speaking from his own experience, the author presents an activist's perspective on hospital boards; but service to other types of not-for-profit institutions involves similar demands for change.     

Implications of Applying a Private Sector Based Reporting Model to Not-for-Profit Entities: The Treatment of Charitable Distributions by Charities in New Zealand

In this paper, we investigate the practical and conceptual difficulties caused by applying a private sector based reporting model to the not-for-profit sector. We deal specifically with reporting on charitable distributions by charities in New Zealand. We find a majority of the entities report charitable distributions in the Statement of Financial Performance (as expenses). This approach is conceptually justifiable, complies with international best practice, and is in line with the accountability argument made in this paper. While the number reduced between 2003 and 2007, a significant minority of the entities report charitable distributions in the Statement of Movements in Equity (and therefore report higher surpluses). These two approaches lead to very different results, yet both are apparently seen as acceptable by the entities and their auditors. While this raises questions as to the understandability and comparability of the financial reporting by these entities, it also raises questions about the suitability of the for-profit sector reporting requirements for the not-for-profit sector.     

政府控制、制度背景与资本结构动态调整

本文研究了政府控制和制度环境与上市公司资本结构动态调整的关系。政府控制同时产生股权限制和融债优势两种相反的作用力,更有利于债权融资调整,不利于股权融资调整,使得国家持股比例与调整速度之间呈现倒U形关系;流通股的增加扩大了融资摩擦,减缓了调整速度。政府分级增加了地方政府控制企业的融资成本,不利于调整的发生;欠发达的市场化进程扩大了政府分级的融资成本,尚不足以提供资源配置的无障碍平台。政府控制企业和非政府控制企业的调整决策差异,反映了它们理性经济行为的次优选择。