Conversion of HMOs and Hospitals: What's at Stake?

Health Affairs

Volumn 16, Issue 2, 1997, Pages 29-47

  Gray, Bradford H ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

HEALTH CARE FACILITY; HEALTH CARE POLICY; HEALTH MAINTENANCE ORGANIZATION; HOSPITAL; HOSPITAL ORGANIZATION; NON PROFIT HOSPITAL; NON PROFIT ORGANIZATION; ORGANIZATION; ORGANIZATION AND MANAGEMENT; REVIEW; UNITED STATES;

HEALTH FACILITY MERGER; HEALTH FACILITY PLANNING; HEALTH MAINTENANCE ORGANIZATIONS; HEALTH POLICY; HOSPITAL RESTRUCTURING; HOSPITALS, PROPRIETARY; HOSPITALS, VOLUNTARY; ORGANIZATIONAL INNOVATION; ORGANIZATIONS, NONPROFIT; OWNERSHIP; UNITED STATES;

EID: 0000953769     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.16.2.29     Document Type: Article

References (64)

1. The earliest hospital conversion of which I am aware occurred prior to 1970. E. Hoy and B.H. Gray, "The Growth of the Major Investor-Owned Hospital Companies," in B.H. Gray, ed., Far-Profit Enterprise in Health Care (Washington: National Academy Press, 1986), Table 5. The earliest HMO conversion to which I have seen reference occurred in 1978. See K.C. Dunn et al., "The Dynamics of Leveraged Buy-Outs, Conversions, and Corporate Reorganizations of Not-for-Profit Health Care Institutions," Topics in Health Care Financing (Spring 1986): 19-34.
2. The earliest hospital conversion of which I am aware occurred prior to 1970. E. Hoy and B.H. Gray, "The Growth of the Major Investor-Owned Hospital Companies," in B.H. Gray, ed., Far-Profit Enterprise in Health Care (Washington: National Academy Press, 1986), Table 5. The earliest HMO conversion to which I have seen reference occurred in 1978. See K.C. Dunn et al., "The Dynamics of Leveraged Buy-Outs, Conversions, and Corporate Reorganizations of Not-for-Profit Health Care Institutions," Topics in Health Care Financing (Spring 1986): 19-34.
3. D.M. Fox and P. Isenberg, "Anticipating the Magic Moment: The Public Interest in Health Plan Conversions in California," Health Affairs (Spring 1996): 202-209.
4. Ibid.; and C. McDermott, "The Changing Health Care Scene and Health Philanthropy: The New 'Conversion Foundations'" (Presentation at the Council on Foundations Annual Conference, Atlanta, Georgia, 23 April 1996).
5. Ibid.; and C. McDermott, "The Changing Health Care Scene and Health Philanthropy: The New 'Conversion Foundations'" (Presentation at the Council on Foundations Annual Conference, Atlanta, Georgia, 23 April 1996).
6. H. Hansmann, "The Role of Nonprofit Organizations," Yale Law Journal 89, no. 5 (1980): 835-901.
7. In interviews at Humana in 1987, I was told that as much as 50 percent of the chief executive's compensation in Humana hospitals was in incentives tied to economic goals set by the corporation. Columbia/HCA establishes local joint ventures that own hospitals or other facilities, with local doctors and executives as investors. Robert Kuttner was told by a Columbia/HCA executive that hospital executives who fall short of the corporate goal of a 20 percent gross return on revenues are "regularly called to corporate headquarters in Nashville to explain and are ordered to redouble their efforts." See R. Kuttner, "Columbia/HCA and the Resurgence of the For-Profit Hospital Business" (Part 1), The New England Journal of Medicine (1 August 1996): 362-367.
8. At least six HMO companies have had price/earnings ratios in excess of thirty in recent years; HMO companies are generally far below that now. See Sherlock Company P.U.LS.E. Report, September 1995, cited in The Henry J. Kaiser Family Foundation, Chart Pack, "Marcus Welby Goes to Wall Street" (13 December 1995).
9. At least six HMO companies have had price/earnings ratios in excess of thirty in recent years; HMO companies are generally far below that now. See Sherlock Company P.U.LS.E. Report, September 1995, cited in The Henry J. Kaiser Family Foundation, Chart Pack, "Marcus Welby Goes to Wall Street" (13 December 1995).
10. J. Copeland and G. Rudney, "Federal Tax Subsidies for Not-for-Profit Hospitals," Tax Notes (26 March 1990): 1565. Nonprofit hospitals' total margins fell from 7.6 percent of revenues in the first year of PPS to less than 4 percent within three years. See Prospective Payment Assessment Commission, Medicare and the American Health Care System: Report to the Congress, June 1995 (Washington: ProPAC, 1995), 56. More recently, Nancy Kane, in an HCA-funded study, concluded that the cost of tax exemption among Virginia hospitals was about 8.4 percent of revenues (see Kuttner, "Columbia/HCA and the Resurgence of the For-Profit Hospital Business," 365), an amount that exceeded the difference between nonprofits and for-profits in the amount of free care they are providing (3.7 percent versus 1.7 percent of revenues) and education (1.1 percent versus nothing). An issue raised by such analyses is whether the community benefit activities of nonprofit health care organizations are more beneficial to communities than are taxes paid by health care companies.
11. J. Copeland and G. Rudney, "Federal Tax Subsidies for Not-for-Profit Hospitals," Tax Notes (26 March 1990): 1565. Nonprofit hospitals' total margins fell from 7.6 percent of revenues in the first year of PPS to less than 4 percent within three years. See Prospective Payment Assessment Commission, Medicare and the American Health Care System: Report to the Congress, June 1995 (Washington: ProPAC, 1995), 56. More recently, Nancy Kane, in an HCA-funded study, concluded that the cost of tax exemption among Virginia hospitals was about 8.4 percent of revenues (see Kuttner, "Columbia/HCA and the Resurgence of the For-Profit Hospital Business," 365), an amount that exceeded the difference between nonprofits and for-profits in the amount of free care they are providing (3.7 percent versus 1.7 percent of revenues) and education (1.1 percent versus nothing). An issue raised by such analyses is whether the community benefit activities of nonprofit health care organizations are more beneficial to communities than are taxes paid by health care companies.
12. J. Copeland and G. Rudney, "Federal Tax Subsidies for Not-for-Profit Hospitals," Tax Notes (26 March 1990): 1565. Nonprofit hospitals' total margins fell from 7.6 percent of revenues in the first year of PPS to less than 4 percent within three years. See Prospective Payment Assessment Commission, Medicare and the American Health Care System: Report to the Congress, June 1995 (Washington: ProPAC, 1995), 56. More recently, Nancy Kane, in an HCA-funded study, concluded that the cost of tax exemption among Virginia hospitals was about 8.4 percent of revenues (see Kuttner, "Columbia/HCA and the Resurgence of the For-Profit Hospital Business," 365), an amount that exceeded the difference between nonprofits and for-profits in the amount of free care they are providing (3.7 percent versus 1.7 percent of revenues) and education (1.1 percent versus nothing). An issue raised by such analyses is whether the community benefit activities of nonprofit health care organizations are more beneficial to communities than are taxes paid by health care companies.
13. See, for example, J.H. Parker et al., "Analysis of Central Florida Hospital Community Benefits: Community Hospitals Compared to Investor-Owned Hospitals" (Report prepared for Florida Hospital and Orlando Regional Healthcare System, July 1995).
14. A legal issue that may arise in these circumstances is what share of a non-profit's assets can be sold before the need for approval as a nonprofit conversion is triggered. Hypothetically, a nonprofit could put all of its assets into a for-profit subsidiary and then sell the subsidiary.
15. It is difficult to compare organizations such as hospitals that provide differing mixes of services to diverse patient populations. Depending upon the way that efficiency is defined, chronically underfunded public hospitals may be the most efficient in that they serve the most patients for the least money. As a practical matter, most studies have compared hospital expenses or charges on either a per day or a per stay basis, using a case-mix adjustment to compensate for some hospitals (for example, major teaching hospitals) having a much sicker population of patients than others have. But these comparisons are seldom discussed in terms of efficiency, since it is not clear that a hospital day or a hospital stay is a standard or meaningful measure. On the second point, see, for example, B.H. Gray, The Profit Motive and Patient Care (Cambridge: Harvard University Press, 1991), chap. 5.
16. R. Stevens, In Sickness and in Wealth: The American Hospital in the Twentieth Century (New York: Basic Books, 1989).
17. The conversion of nonprofits should not be imagined as a solution to the problem of the uninsured. In "Let's End the Nonprofit Charade," The New England Journal of Medicine (18 April 1996): 1057, Malik Hasan, chief executive officer of Health Systems International, a for-profit managed care company, avers that $92 billion would be raised by the conversion of nonprofit health plans. Although a significant amount of money, this one-time source of funding would cover the uninsured for about one year.
18. Other alternatives for underused hospitals include changing the use of a facility, making a hospital primarily an outpatient or a long-term care facility.
19. Hasan, "Let's End the Nonprofit Charade."
20. An example is Columbia/HCA's troubled acquisition of Blue Cross and Blue Shield of Ohio, in which the chairman of Blue Shield reportedly is to receive $3 million under an agreement not to compete and $7 million for managing the transaction, and its chief counsel and an outside counsel are each to receive $3.5 million. This has been described as a "thinly disguised kickback for selling out at a lowball price." See H.W. Jenkins Jr., "To the Rationalizers Go the Spoils," The Wall Street Journal, 30 July 1996, A15. Jenkins's view is that "17 million dollars hardly seems worth getting out of bed for" and that "in an economy that dumps millions on a Snoop Doggy Dogg, it would be hard to begrudge Mr. Burry [the Blue Cross chairman] and colleagues a nice reward for honest labors."
21. See K. Barnett, Community Benefit Law and California Hospitals: Opportunities and Challenges of SB 697 (Berkeley, Calif.: Western Consortium for Public Health, 1995); and National Health Lawyers Association, Colloquium Report on Legal Issues Related to Tax Exemption and Community Benefit (Washington: NHLA, 1996).
22. See K. Barnett, Community Benefit Law and California Hospitals: Opportunities and Challenges of SB 697 (Berkeley, Calif.: Western Consortium for Public Health, 1995); and National Health Lawyers Association, Colloquium Report on Legal Issues Related to Tax Exemption and Community Benefit (Washington: NHLA, 1996).
23. M.V. Pauly, "Health Systems Ownership: Can Regulation Preserve Community Benefits?" and B.H. Gray, "Tax Exemptions as Health Policy," in Frontiers of Health Services Management 12, no. 3 (1996): 3-34 and 37-42.
24. M.V. Pauly, "Health Systems Ownership: Can Regulation Preserve Community Benefits?" and B.H. Gray, "Tax Exemptions as Health Policy," in Frontiers of Health Services Management 12, no. 3 (1996): 3-34 and 37-42.
25. K.J. Arrow, "Uncertainty and the Welfare Economics of Medical Care," American Economic Review 53, no. 5 (1963): 941-973.
26. Hansmann, "The Role of Nonprofit Organizations." Hansmann focuses on contract failure problems involving patients, but there have also been problems between payers and providers. The proliferation of for-profit health care organizations over the past three decades has been accompanied by an apparent efflorescence of fraud in health care and recurrent extensions and strengthening of federal fraud-and-abuse legislation. See Gray, The Profit Motive and Patient Care, chap. 6.
27. Hansmann, "The Role of Nonprofit Organizations." Hansmann focuses on contract failure problems involving patients, but there have also been problems between payers and providers. The proliferation of for-profit health care organizations over the past three decades has been accompanied by an apparent efflorescence of fraud in health care and recurrent extensions and strengthening of federal fraud-and-abuse legislation. See Gray, The Profit Motive and Patient Care, chap. 6.
28. Hansmann, "The Role of Nonprofit Organizations."
29. See Gray, The Profit Motive and Patient Care, chaps. 8 and 10.
30. Ibid., 136-137.
31. Kuttner, "Columbia/HCA and the Resurgence of the For-Profit Hospital Business," 362. Wall Street Journal reporter Robert Tomsho described Columbia/ HCA's physician partnership strategy in 1994: "Columbia has been building and buying outpatient-service facilities and wooing referring physicians with lavish entertainment and lucrative offers to become Columbia investors. . . . Columbia has been making investment offers just as many physicians have been forced to divest themselves of direct ownership of outpatient facilities such as diagnostic clinics amid new state and federal regulations designed to prevent their overuse. . . . Columbia has responded by bundling such facilities with its hospitals into regional investment packages and offering local doctors the opportunity to acquire up to a 40% stake in the entire network. Federal guidelines generally permit such arrangements so long as physician-investors don't own more than 40% of an entity or generate more than 40% of its revenues. Nevertheless, Columbia acknowledges that some of its joint-venture agreements with physicians may not meet the stricter rules that federal regulators have threatened to impose in some of these circumstances. 'There's a great big gray area,' says Stephen Braun, Columbia's general counsel." See R. Tomsho, "Giant Hospital Chain Uses Tough Tactics to Push Fast Growth," The Wall Street Journal, 12 July 1994, P1.
32. Kuttner, "Columbia/HCA and the Resurgence of the For-Profit Hospital Business," 362. Wall Street Journal reporter Robert Tomsho described Columbia/ HCA's physician partnership strategy in 1994: "Columbia has been building and buying outpatient-service facilities and wooing referring physicians with lavish entertainment and lucrative offers to become Columbia investors. . . . Columbia has been making investment offers just as many physicians have been forced to divest themselves of direct ownership of outpatient facilities such as diagnostic clinics amid new state and federal regulations designed to prevent their overuse. . . . Columbia has responded by bundling such facilities with its hospitals into regional investment packages and offering local doctors the opportunity to acquire up to a 40% stake in the entire network. Federal guidelines generally permit such arrangements so long as physician-investors don't own more than 40% of an entity or generate more than 40% of its revenues. Nevertheless, Columbia acknowledges that some of its joint-venture agreements with physicians may not meet the stricter rules that federal regulators have threatened to impose in some of these circumstances. 'There's a great big gray area,' says Stephen Braun, Columbia's general counsel." See R. Tomsho, "Giant Hospital Chain Uses Tough Tactics to Push Fast Growth," The Wall Street Journal, 12 July 1994, P1.
33. Kuttner, "Columbia/HCA and the Resurgence of the For-Profit Hospital Business," 365.
34. J.M. Sever, "Navigating the Changing Healthcare System: The Towers Perrin Survey of What Americans Know and Need to Know" (New York: Louis Harris and Associates, 1995).
35. M.V. Pauly et al., "Managing Physician Incentives in Managed Care: The Role of For-Profit Ownership," Medical Care (November 1990): 1013-1024.
36. Prospective Payment Assessment Commission, "Enrollment and Disenrollment Experience in the Medicare Risk Program" (Washington: ProPAC, 19 December 1994).
37. G. Anders, "Humana Gets Some of the Poorest Scores in Study of HMO Medicare Complaints," The Wall Street Journal, 31 January 1995, B5.
38. Calculated from plan-specific data reported in "How Good Is Your Health Plan?" Consumer Reports (August 1996): 40.
39. B.A. Weisbrod, The Nonprofit Economy (Cambridge: Harvard University Press, 1988), 18-19.
40. To improve its ability to acquire nonprofit hospitals, Columbia/HCA has been particularly aggressive in arguing that nonprofits do not deserve their tax exemptions. The famous Washington Post quote from CEO Richard Scott is that "nontaxpaying hospitals shouldn't be in business." See Kuttner, "Columbia/ HCA and the Resurgence of the For-Profit Hospital Business," 448.
41. Complexities include whether "charity" patients should have to be designated in advance or whether charity also includes patients who prove unable to pay their bills. In addition, because the costs of services can vary enormously, it makes more sense to measure the extent of charity care in dollar terms rather than in number of patients. But requiring the documentation of the costs of the services provided to particular patients - as opposed to the hospital's charges for such services - could be quite onerous, perhaps requiring a new cost accounting system. On the other hand, measuring uncompensated care in terms of charges would make the amount of charity care an organization provides a function, in part, of the size of the gap between the hospital's costs and its charges. See L.S. Lewin, T. Eckles, and L. Miller, "Setting the Record Straight: The Provision of Uncompensated Care by Not-for-Profit Hospitals," The New England Journal of Medicine (5 May 1988): 1212-1215.
42. A 1993 report by Healthcare Management Decisions for Columbia/HCA contended that several southwest Florida hospitals provided less community benefit than the value of their tax exemptions. The only community benefit that was counted, however, was the hospitals' "charity care" deduction from revenue; even other tangible measures (losses on Medicaid payments and unreimbursed educational costs) were ignored. An independent study sponsored by the Association of Voluntary Hospitals of Florida, using a broader (though still relatively narrow) measure of community benefit, concluded that voluntary hospitals (both publics and nonprofits) provided much larger amounts of community benefits than did for-profits, and substantially more than the value of their tax exemptions.
43. J. Ashby, The Trend and Distribution of Hospital Uncompensated Care Costs, 1980-1989 (Washington: Prospective Payment Assessment Commission, 1991). John Ashby shows that the oft-noted higher levels of uncompensated care provided by public hospitals shrink greatly when direct governmental subsidies are counted.
44. Prospective Payment Assessment Commission, Medicare and the American Health Care System: Report to the Congress (Washington: ProPAC, 1996), 84.
45. For example, Connecticut (with about 11 percent uninsured) and Massachusetts (with about 13 percent uninsured) had no for-profit hospitals until 1996, while Florida (about 23 percent uninsured) and Texas (about 26 percent uninsured) have large numbers of for-profit hospitals.
46. The 1986 Institute of Medicine report on For-Profit Enterprise in Health Care makes this point and summarizes the literature to that date. For subsequent evidence, see Lewin et al., "Setting the Record Straight;" Gray, The Profit Motive and Patient Care; and B. Arrington and C.C. Haddock, "Who Really Profits from Not-for-Profits?" Health Services Research (June 1990): 290-304. A more recent series of reports on Florida, Virginia, Georgia, and Tennessee for 1993 or 1994 shows that for-profit hospitals provide much less than their proportionate share of charity or indigent care. Unfortunately, these reports do not distinguish between governmental and private nonprofit hospitals. In Georgia, B.A. Brotman, "Hospital Indigent Care Expenditures," Journal of Health Care Financing 21, no. 4 (1995): 76-79, claims without presenting data that there is no non-profit/for-profit difference in "indigent care" expenses because of a regulatory requirement that all hospitals devote at least 3 percent of revenues to indigent care.
47. The 1986 Institute of Medicine report on For-Profit Enterprise in Health Care makes this point and summarizes the literature to that date. For subsequent evidence, see Lewin et al., "Setting the Record Straight;" Gray, The Profit Motive and Patient Care; and B. Arrington and C.C. Haddock, "Who Really Profits from Not-for-Profits?" Health Services Research (June 1990): 290-304. A more recent series of reports on Florida, Virginia, Georgia, and Tennessee for 1993 or 1994 shows that for-profit hospitals provide much less than their proportionate share of charity or indigent care. Unfortunately, these reports do not distinguish between governmental and private nonprofit hospitals. In Georgia, B.A. Brotman, "Hospital Indigent Care Expenditures," Journal of Health Care Financing 21, no. 4 (1995): 76-79, claims without presenting data that there is no non-profit/for-profit difference in "indigent care" expenses because of a regulatory requirement that all hospitals devote at least 3 percent of revenues to indigent care.
48. The 1986 Institute of Medicine report on For-Profit Enterprise in Health Care makes this point and summarizes the literature to that date. For subsequent evidence, see Lewin et al., "Setting the Record Straight;" Gray, The Profit Motive and Patient Care; and B. Arrington and C.C. Haddock, "Who Really Profits from Not-for-Profits?" Health Services Research (June 1990): 290-304. A more recent series of reports on Florida, Virginia, Georgia, and Tennessee for 1993 or 1994 shows that for-profit hospitals provide much less than their proportionate share of charity or indigent care. Unfortunately, these reports do not distinguish between governmental and private nonprofit hospitals. In Georgia, B.A. Brotman, "Hospital Indigent Care Expenditures," Journal of Health Care Financing 21, no. 4 (1995): 76-79, claims without presenting data that there is no non-profit/for-profit difference in "indigent care" expenses because of a regulatory requirement that all hospitals devote at least 3 percent of revenues to indigent care.
49. The 1986 Institute of Medicine report on For-Profit Enterprise in Health Care makes this point and summarizes the literature to that date. For subsequent evidence, see Lewin et al., "Setting the Record Straight;" Gray, The Profit Motive and Patient Care; and B. Arrington and C.C. Haddock, "Who Really Profits from Not-for-Profits?" Health Services Research (June 1990): 290-304. A more recent series of reports on Florida, Virginia, Georgia, and Tennessee for 1993 or 1994 shows that for-profit hospitals provide much less than their proportionate share of charity or indigent care. Unfortunately, these reports do not distinguish between governmental and private nonprofit hospitals. In Georgia, B.A. Brotman, "Hospital Indigent Care Expenditures," Journal of Health Care Financing 21, no. 4 (1995): 76-79, claims without presenting data that there is no non-profit/for-profit difference in "indigent care" expenses because of a regulatory requirement that all hospitals devote at least 3 percent of revenues to indigent care.
50. Ashby notes that the subsidies received by public hospitals account for virtually all of the oft-reported difference between public and private hospitals in the amount of uncompensated care they provide. Ashby, The Trend and Distribution of Hospital Uncompensated Care Costs, 13. The large number of public hospitals in California may help to explain why nonprofit and for-profit hospitals provide similarly low amounts of uncompensated care in that state.
51. D. Rowland, "Hospital Care for the Uninsured: An Analysis of the Role of Proprietary Hospitals" (Presentation at the Annual Meeting of the American Public Health Association, Anaheim, California, 1984); and R. Frank, D.S. Salkever, and F. Mullan, "Hospital Ownership and the Care of Uninsured and Medicaid Patients: Findings from the National Hospital Discharge Survey, 1979-1984," Health Policy 14, no. 1 (1990): 1-11.
52. D. Rowland, "Hospital Care for the Uninsured: An Analysis of the Role of Proprietary Hospitals" (Presentation at the Annual Meeting of the American Public Health Association, Anaheim, California, 1984); and R. Frank, D.S. Salkever, and F. Mullan, "Hospital Ownership and the Care of Uninsured and Medicaid Patients: Findings from the National Hospital Discharge Survey, 1979-1984," Health Policy 14, no. 1 (1990): 1-11.
53. M. Schlesinger et al., "The Privatization of Health Care and Physicians' Perceptions of Access to Hospital Services," The Milbank Quarterly 65, no. 1 (1987): 25-58; and L.R. Burns, R.M. Anderson, and S.M. Shortell, "The Effect of Hospital Control Strategies on Physician Satisfaction and Physician-Hospital Conflict," Health Services Research (August 1990): 527-558.
54. M. Schlesinger et al., "The Privatization of Health Care and Physicians' Perceptions of Access to Hospital Services," The Milbank Quarterly 65, no. 1 (1987): 25-58; and L.R. Burns, R.M. Anderson, and S.M. Shortell, "The Effect of Hospital Control Strategies on Physician Satisfaction and Physician-Hospital Conflict," Health Services Research (August 1990): 527-558.
55. M. Schlesinger, E. Bradley, and B.H. Gray, "Charity and Community: The Role of Nonprofit Ownership in a Managed Health Care System," Journal of Health Politics, Policy and Law (Winter 1996): 697-751.
56. See Gray, ed., For-Profit Enterprise in Health Care; Gray, The Profit Motive and Patient Care; J. Alexander, B. Lewis, and M. Morrisey, "Acquisition Strategies of Multi-hospital Systems," Health Affairs (Winter 1985): 49-66; E.C. Norton and D.O. Staiger, "How Hospital Ownership Affects Access to Care for the Uninsured," RAND Journal of Economics (Spring 1994): 171-185; A.J. LeBlanc and R.E. Hurley, "Adoption of HIV-Related Services among Urban U.S. Hospitals: 1988 and 1991," Medical Care 33, no. 9 (1995): 881-891; ProPAC, "Comparison of HMOs across Payer Types," Staff Report (Washington: ProPAC, January 1995); H.S. Luft and M.R. Greenlick, "The Contribution of Group- and Staff-Model HMOs to American Medicine," The Milbank Quarterly 74, no. 4 (1996): 445-468; and J. Veloski et al., "Medical Student Education in Managed Care Settings: Beyond HMOs," Journal of the American Medical Association (4 September 1996): 667-671.
57. See Gray, ed., For-Profit Enterprise in Health Care; Gray, The Profit Motive and Patient Care; J. Alexander, B. Lewis, and M. Morrisey, "Acquisition Strategies of Multi-hospital Systems," Health Affairs (Winter 1985): 49-66; E.C. Norton and D.O. Staiger, "How Hospital Ownership Affects Access to Care for the Uninsured," RAND Journal of Economics (Spring 1994): 171-185; A.J. LeBlanc and R.E. Hurley, "Adoption of HIV-Related Services among Urban U.S. Hospitals: 1988 and 1991," Medical Care 33, no. 9 (1995): 881-891; ProPAC, "Comparison of HMOs across Payer Types," Staff Report (Washington: ProPAC, January 1995); H.S. Luft and M.R. Greenlick, "The Contribution of Group- and Staff-Model HMOs to American Medicine," The Milbank Quarterly 74, no. 4 (1996): 445-468; and J. Veloski et al., "Medical Student Education in Managed Care Settings: Beyond HMOs," Journal of the American Medical Association (4 September 1996): 667-671.
58. See Gray, ed., For-Profit Enterprise in Health Care; Gray, The Profit Motive and Patient Care; J. Alexander, B. Lewis, and M. Morrisey, "Acquisition Strategies of Multi-hospital Systems," Health Affairs (Winter 1985): 49-66; E.C. Norton and D.O. Staiger, "How Hospital Ownership Affects Access to Care for the Uninsured," RAND Journal of Economics (Spring 1994): 171-185; A.J. LeBlanc and R.E. Hurley, "Adoption of HIV-Related Services among Urban U.S. Hospitals: 1988 and 1991," Medical Care 33, no. 9 (1995): 881-891; ProPAC, "Comparison of HMOs across Payer Types," Staff Report (Washington: ProPAC, January 1995); H.S. Luft and M.R. Greenlick, "The Contribution of Group- and Staff-Model HMOs to American Medicine," The Milbank Quarterly 74, no. 4 (1996): 445-468; and J. Veloski et al., "Medical Student Education in Managed Care Settings: Beyond HMOs," Journal of the American Medical Association (4 September 1996): 667-671.
59. See Gray, ed., For-Profit Enterprise in Health Care; Gray, The Profit Motive and Patient Care; J. Alexander, B. Lewis, and M. Morrisey, "Acquisition Strategies of Multi-hospital Systems," Health Affairs (Winter 1985): 49-66; E.C. Norton and D.O. Staiger, "How Hospital Ownership Affects Access to Care for the Uninsured," RAND Journal of Economics (Spring 1994): 171-185; A.J. LeBlanc and R.E. Hurley, "Adoption of HIV-Related Services among Urban U.S. Hospitals: 1988 and 1991," Medical Care 33, no. 9 (1995): 881-891; ProPAC, "Comparison of HMOs across Payer Types," Staff Report (Washington: ProPAC, January 1995); H.S. Luft and M.R. Greenlick, "The Contribution of Group- and Staff-Model HMOs to American Medicine," The Milbank Quarterly 74, no. 4 (1996): 445-468; and J. Veloski et al., "Medical Student Education in Managed Care Settings: Beyond HMOs," Journal of the American Medical Association (4 September 1996): 667-671.
60. See Gray, ed., For-Profit Enterprise in Health Care; Gray, The Profit Motive and Patient Care; J. Alexander, B. Lewis, and M. Morrisey, "Acquisition Strategies of Multi-hospital Systems," Health Affairs (Winter 1985): 49-66; E.C. Norton and D.O. Staiger, "How Hospital Ownership Affects Access to Care for the Uninsured," RAND Journal of Economics (Spring 1994): 171-185; A.J. LeBlanc and R.E. Hurley, "Adoption of HIV-Related Services among Urban U.S. Hospitals: 1988 and 1991," Medical Care 33, no. 9 (1995): 881-891; ProPAC, "Comparison of HMOs across Payer Types," Staff Report (Washington: ProPAC, January 1995); H.S. Luft and M.R. Greenlick, "The Contribution of Group- and Staff-Model HMOs to American Medicine," The Milbank Quarterly 74, no. 4 (1996): 445-468; and J. Veloski et al., "Medical Student Education in Managed Care Settings: Beyond HMOs," Journal of the American Medical Association (4 September 1996): 667-671.
61. See Gray, ed., For-Profit Enterprise in Health Care; Gray, The Profit Motive and Patient Care; J. Alexander, B. Lewis, and M. Morrisey, "Acquisition Strategies of Multi-hospital Systems," Health Affairs (Winter 1985): 49-66; E.C. Norton and D.O. Staiger, "How Hospital Ownership Affects Access to Care for the Uninsured," RAND Journal of Economics (Spring 1994): 171-185; A.J. LeBlanc and R.E. Hurley, "Adoption of HIV-Related Services among Urban U.S. Hospitals: 1988 and 1991," Medical Care 33, no. 9 (1995): 881-891; ProPAC, "Comparison of HMOs across Payer Types," Staff Report (Washington: ProPAC, January 1995); H.S. Luft and M.R. Greenlick, "The Contribution of Group- and Staff-Model HMOs to American Medicine," The Milbank Quarterly 74, no. 4 (1996): 445-468; and J. Veloski et al., "Medical Student Education in Managed Care Settings: Beyond HMOs," Journal of the American Medical Association (4 September 1996): 667-671.
62. See Gray, ed., For-Profit Enterprise in Health Care; Gray, The Profit Motive and Patient Care; J. Alexander, B. Lewis, and M. Morrisey, "Acquisition Strategies of Multi-hospital Systems," Health Affairs (Winter 1985): 49-66; E.C. Norton and D.O. Staiger, "How Hospital Ownership Affects Access to Care for the Uninsured," RAND Journal of Economics (Spring 1994): 171-185; A.J. LeBlanc and R.E. Hurley, "Adoption of HIV-Related Services among Urban U.S. Hospitals: 1988 and 1991," Medical Care 33, no. 9 (1995): 881-891; ProPAC, "Comparison of HMOs across Payer Types," Staff Report (Washington: ProPAC, January 1995); H.S. Luft and M.R. Greenlick, "The Contribution of Group- and Staff-Model HMOs to American Medicine," The Milbank Quarterly 74, no. 4 (1996): 445-468; and J. Veloski et al., "Medical Student Education in Managed Care Settings: Beyond HMOs," Journal of the American Medical Association (4 September 1996): 667-671.
63. See Gray, ed., For-Profit Enterprise in Health Care; Gray, The Profit Motive and Patient Care; J. Alexander, B. Lewis, and M. Morrisey, "Acquisition Strategies of Multi-hospital Systems," Health Affairs (Winter 1985): 49-66; E.C. Norton and D.O. Staiger, "How Hospital Ownership Affects Access to Care for the Uninsured," RAND Journal of Economics (Spring 1994): 171-185; A.J. LeBlanc and R.E. Hurley, "Adoption of HIV-Related Services among Urban U.S. Hospitals: 1988 and 1991," Medical Care 33, no. 9 (1995): 881-891; ProPAC, "Comparison of HMOs across Payer Types," Staff Report (Washington: ProPAC, January 1995); H.S. Luft and M.R. Greenlick, "The Contribution of Group- and Staff-Model HMOs to American Medicine," The Milbank Quarterly 74, no. 4 (1996): 445-468; and J. Veloski et al., "Medical Student Education in Managed Care Settings: Beyond HMOs," Journal of the American Medical Association (4 September 1996): 667-671.
64. M. Schlesinger, "Mismeasuring the Consequences of Ownership: External Influences and the Comparative Performance of Public, For-Profit, and Non-profit Organizations" (Working Paper 204, Program on Non-Profit Organizations, Yale University, 1995).