The transformation of French hospital capitalism: financialisation and concentration

Characteristics and patterns of elective admissions to for-profit and not-for-profit hospitals in France in 2009 and 2010

The dynamics of health care delivery for children and adolescents have greatly evolved over the last 5 years. The growth of managed care has been especially rapid, and has coincided with other fundamental changes—declines in private coverage, growth of Medicaid, welfare reform, and the creation of the state Child Health Insurance Program (CHIP).1 Over the past 10 years, the number of children covered through employer-sponsored plans and other private plans has dropped.2 During this same period, changes to Medicaid have begun to de-couple eligibility from welfare eligibility, theoretically enabling states to expand coverage. For children, this movement from private to public coverage has accelerated the movement to managed care systems. Between 1991 and 1997, Medicaid enrollment in managed care plans increased from 9.5% to 47.8% of total Medicaid enrollment.3 Recent estimates suggest that over half of these Medicaid managed care enrollees are children.4 However, little is known about the impact of these trends on children's access to and use of services, let alone the quality and outcomes of that care. This report is the first in what is anticipated to be an annual series of reports on access to and use of health care services by America's children and youth. The report capitalizes on the existence of 2 national datasets, the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (HCUP), which have not been widely used by the child health services research community. As background to these new sources of data, we have provided a detailed description of the datasets, and review some of the fundamental tabulations. In future years, as more data are accumulated, these reports will focus on delineation of key trends and analyses addressing policy issues. ### MEPS The MEPS is conducted to provide nationally representative estimates of health care use, …

I. INTRODUCTION The prevalence of for-profit hospitals has increased in the United States over the past few decades. The emergence of for-profit hospitals that often compete in markets with not-for-profit hospitals has generated vigorous academic and policy debates about the implications of the distinct legal and organizational for-profit and non-profit forms on hospital behavior. The main issues arise from differences in monetary and non-pecuniary incentives for administrators and physicians that are associated with organizational form, including variations in tax treatment, access to capital markets, and governance structures. These debates center on two possible outcomes related to organizational form and ownership mix. One is whether these differences lead to observable differences in revenues and costs as well as the quantity, quality, and mix of services provided by for-profit and non-profit hospitals (NPHs). The other possible outcome is whether competition from for-profit hospitals in the same markets as NPHs coupled with persistent cost-containment efforts of public and private insurers, results in a form of convergence where NPHs behave similarly to for-profit hospitals despite differences in organizational form. This notion of convergence that has arisen in the literature on performance in the hospital industry has called into question both academically and for policy makers the tax benefits that NPHs enjoy on the grounds that NPHs are indistinguishable from for-profit hospitals and fail to provide community benefits at a level sufficient to justify the subsidies. (1) The ongoing debate about whether NPHs behave differently from for-profit hospitals has given rise to a substantial empirical literature seeking to inform the debate. Schlesinger and Gray (2006) and Rosenau (2003) comprehensively reviewed the empirical evidence on the performance differences between for-profit and NPHs. Performance is evaluated along several dimensions including economic measures like cost per admission, revenue or charge per admission, technical efficiency, non-pecuniary measures like quality, provision of care to indigent patients, and trustworthiness of organizational practices. Both reviews conclude that ownership-related differences in hospital behavior and outcomes are mixed. Schlesinger and Gray reviewed 162 empirical studies comparing non-profit and for-profit hospitals and nursing homes along the dimensions of economic performance, quality of care, and indigent patients' access to care. (2) In terms of economic performance, 18 studies found no significant differences between for-profit and NPHs; 10 studies found an advantage for profit-making hospitals (PMHs); and 30 found an advantage for NPHs. Twenty-one studies reported no significant differences between for-profit and NPHs in terms of quality of care, whereas 4 studies found higher quality of care in for-profit hospitals, and 19 studies found higher quality of care in NPHs. Rosenau synthesized the results of approximately 75 peer-reviewed studies published between 1985 and 2001 along quality, cost, access, and charity care dimensions. (3) In terms of cost, 23 studies found NPHs to be superior, 5 studies found for-profit hospitals to be superior, and 9 studies were inconclusive. Twelve studies found that NPHs provided higher quality care, 3 studies found quality of care to be higher in for-profit hospitals, and 9 studies found no differences in quality. Their finding that evidence of ownershiprelated differences in cost, quality, profits, pricing policies, technical efficiency, access to care, and service offerings vary greatly across empirical studies is not surprising because the studies themselves vary in terms of data used and statistical methods. The empirical approach taken in the majority of the studies is to estimate a reduced-form model of hospital characteristics that typically includes an indicator variable for ownership status as a control variable. …

The variability in resources for managing critical events among maternity hospitals may impact maternal safety. Our main objective was to assess the risk of postpartum maternal death according to hospitals' organizational characteristics. A secondary objective aimed to assess the specific risk of death due to postpartum hemorrhage (PPH). This national population-based case-control study included all 2007-2009 postpartum maternal deaths from the national confidential enquiry (n = 147 cases) and a 2010 national representative sample of parturients (n = 14,639 controls). To adjust for referral bias, cases were classified by time when the condition/complication responsible for the death occurred: postpartum maternal deaths due to conditions present before delivery (n = 66) or during or after delivery (n = 81). Characteristics of delivery hospitals included 24/7 on-site availability of an anesthesiologist and an obstetrician, level of perinatal care, number of deliveries annually, and their teaching and profit status. In teaching and other nonprofit hospitals in France, obstetric care is organized on the principle of collective team-based management, while in for-profit hospitals, this organization is based mostly on that of "one woman-one doctor." Logistic regression models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for postpartum maternal death. The risk of maternal death from prepartum conditions was lower for women who gave birth in for-profit compared with teaching hospitals (aOR, 0.3; 95% CI, 0.1-0.8; P = .02) and in hospitals with <1500 vs ≥1500 annual deliveries (aOR, 0.4; 95% CI, 0.1-0.9; P = .02). Conversely, the risk of postpartum maternal death from complications occurring during or after delivery was higher for women who delivered in for-profit compared with teaching hospitals (aOR, 2.8; 95% CI, 1.3-6.0; P = .009), as was the risk of death from PPH in for-profit versus nonprofit hospitals (aOR, 2.8; 95% CI, 1.2-6.5; P = .019). After adjustment for the referral bias related to prepartum morbidity, the risk of postpartum maternal mortality in France differs according to the hospital's organizational characteristics.

In fiscal year 1990, administration accounted for 24.8 percent of total hospital costs in the United States - nearly twice the share in Canada. Studies from the 1970s and early 1980s found high costs, especially for administration, at for-profit hospitals. We calculated administrative costs for 6227 nonfederal hospitals and the total costs of inpatient care for 5201 acute care hospitals in the United States for fiscal year 1994 on the basis of data the hospitals submitted to Medicare. We analyzed similar data for fiscal year 1990. Using multivariate analysis, we assessed the effect of hospital ownership (private not-for-profit, for-profit, and public) on administrative costs, controlling for hospital type, census region, hospital size, and the proportion of revenues derived from outpatient services. We adjusted inpatient costs for local wage levels, hospitals' reporting periods, and case mix. Administrative costs accounted for an average of 26.0 percent of total hospital costs in fiscal year 1994, up 1.2 percentage points from 1990. They increased by 2.2 percentage points, to 34.0 percent, for for-profit hospitals; by 1.2 percentage points, to 24.5 percent, for private not-for-profit hospitals; and by 0.6 percentage point, to 22.9 percent, for public hospitals. In 1994, administration accounted for 37.5 percent of total costs at psychiatric hospitals (44.4 percent at for-profit hospitals) and 33.0 percent of total costs at rehabilitation hospitals (37.7 percent at for-profit hospitals). In a multivariate analysis, for-profit ownership was associated with a 7.9 percent absolute (34 percent relative) increase in the proportion of hospital spending devoted to administration as compared with public hospitals and a 5.7 percent absolute (23 percent relative) increase as compared with private not-for-profit hospitals. Among acute care hospitals, for-profit institutions had higher adjusted costs per discharge ($8,115) than did private not-for-profit ($7,490) or public ($6,507) hospitals. Much of the difference was due to higher administrative costs ($2,289, $1,809, and $1,432 per discharge, respectively). Administrative costs as a percentage of total hospital costs increased in the United States between 1990 and 1994 and were particularly high at for-profit hospitals. Overall costs of care were also higher at for-profit hospitals.

Background: Teaching hospitals have to balance patient and learner needs in their daily routines. To respond to these challenges, non-profit hospitals may perform differently than public and for-profit hospitals because of their non-distribution constraint. Purposes: This study analyzes patient satisfaction data of non-profit teaching hospitals in comparison to teaching hospitals with for-profit and public ownership status. Patient satisfaction is assumed to be an indicator of how patient needs are met regardless of the teaching goals. Approach: The average patient satisfaction ratings for German hospitals (n = 1461) that were published on the ‘klinikbewertungen.de’ German hospital rating platform were collected for a cross-section analysis. Findings: The data show that non-profit teaching hospitals are better rated than for-profit and public teaching hospitals. Non-profit hospitals seem to be more competent in handling the balance between societies’ needs for clinical training and patient needs for a favorable service experience. Practice implications: For-profits hospitals should revisit their business model once they get involved in the provision of public values such as education.

For-profit hospitals for Europe: the case of Britain and France

The authors make the case for expanding the national discussion of inpatient psychiatric beds to recognize and incorporate other vital components of the continuum of care in order to improve outcomes for individuals with serious mental illness. They review the varied terminology applied to psychiatric beds and describe how the location of these beds has changed from primarily state hospitals to the criminal justice system, emergency departments, inpatient units, and the community. The authors propose 10 recommendations related to beds or to contextual issues regarding them. The recommendations address issues of mental illness terminology, criminal and juvenile justice diversion, the Emergency Medical Treatment and Labor Act, mental health technology, and the mental health workforce, among others. Each recommendation is based on findings from publicly available data and clinical observation and is intended to reduce the human and economic costs associated with severe mental illness by promoting a robust, interconnected, and evidence-based system of care that goes beyond beds.

BackgroundThere is growing concern certain not-for-profit hospitals are not providing enough uncompensated care to justify their tax exempt status. Our objective was to compare the amount of uncompensated care provided by not-for-profit (NFP), for-profit (FP) and government owned hospitals.MethodsWe used 2005 state inpatient data (SID) for 10 states to identify patients hospitalized for three common conditions: acute myocardial infarction (AMI), coronary artery bypass grafting (CABG), or childbirth. Uncompensated care was measured as the proportion of each hospital's total admissions for each condition that were classified as being uninsured. Hospitals were categorized as NFP, FP, or government owned based upon data obtained from the American Hospital Association. We used bivariate methods to compare the proportion of uninsured patients admitted to NFP, FP and government hospitals for each diagnosis. We then used generalized linear mixed models to compare the percentage of uninsured in each category of hospital after adjusting for the socioeconomic status of the markets each hospital served.ResultsOur cohort consisted of 188,117 patients (1,054 hospitals) hospitalized for AMI, 82,261 patients (245 hospitals) for CABG, and 1,091,220 patients for childbirth (793 hospitals). The percentage of admissions classified as uninsured was lower in NFP hospitals than in FP or government hospitals for AMI (4.6% NFP; 6.0% FP; 9.5% government; P < .001), CABG (2.6% NFP; 3.3% FP; 7.0% government; P < .001), and childbirth (3.1% NFP; 4.2% FP; 11.8% government; P < .001). In adjusted analyses, the mean percentage of AMI patients classified as uninsured was similar in NFP and FP hospitals (4.4% vs. 4.3%; P = 0.71), and higher for government hospitals (6.0%; P < .001 for NFP vs. government). Likewise, results demonstrated similar proportions of uninsured patients in NFP and FP hospitals and higher levels of uninsured in government hospitals for both CABG and childbirth.ConclusionsFor the three conditions studied NFP and FP hospitals appear to provide a similar amount of uncompensated care while government hospitals provide significantly more. Concerns about the amount of uncompensated care provided by NFP hospitals appear warranted.

Concerns have been expressed about quality of for-profit hospitals and their use of expensive technologies. To determine differences in mortality after admission for acute myocardial infarction (AMI) and in the use of low- and high-tech services for AMI among for-profit, public, and private nonprofit hospitals. Cooperative Cardiovascular Project data for 129,092 Medicare patients admitted for AMI from 1994 to 1995. Mortality at 30 days and 1 year postadmission; use of aspirin, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers at discharge, thrombolytic therapy, catheterization, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass graft (CABG) compared by ownership. Mortality rates at 30 days and at 1 year at for-profit hospitals were no different from those at public and private nonprofit hospitals. Without patient illness variables, nonprofit hospitals had lower mortality rates at 30 days (relative risk [RR], 0.95; 95% confidence interval [CI], 0.91-0.99) and at 1 year (RR, 0.96; 95% CI, 0.93-0.99) than did for-profit hospitals, but there was no difference in mortality between public and for-profit hospitals. Beneficiaries at nonprofit hospitals were more likely to receive aspirin (RR, 1.04; 95% CI, 1.03-1.05) and ACE inhibitors (RR, 1.05; 95% CI, 1.02-1.08) than at for-profit hospitals, but had lower rates of PTCA (RR, 0.91; 95% CI, 0.86-0.96) and CABG (RR, 0.93; 95% CI, 0.86-1.00). Although outcomes did not vary by ownership, for-profit hospitals were more likely to use expensive, high-tech procedures. This pattern appears to be the result of for-profit hospitals' propensity to locate in areas with demand for high-tech care for AMI.

Effect of Hospital Ownership on Outcomes After Left Ventricular Assist Device Implantation in the United States

Do for-profit hospitals cream-skim patients? Evidence from inpatient psychiatric care in California.

In 1961, public hospital insurance created a new form of public-private partnership in Quebec by paying for care given in for-profit (proprietary) hospitals. How did it work? How did for-profit hospitals deal with governmental norms and regulations? Why and how was the door closed on the development of for-profit hospitals after a few years of experimentation? On the whole, this partnership proved to be chaotic and inefficient, plagued by endless negotiations. During the seventies, the government appears finally to have concluded that the partnership was not worthwhile. Public-private partnership in the hospital sector, then, existed well before the federal initiatives but has been largely forgotten, despite the reappearance of similar debates.

Nonprofit, for-profit, and government hospitals are all more likely to offer services when they are relatively profitable than when they are relatively unprofitable. However, for-profit hospitals are considerably more likely than others to provide services based on profitability. After hospital and market characteristics are adjusted for, nonprofit hospitals offer relatively unprofitable services more than for-profit hospitals and less than government hospitals. Profitable services typically exhibit the opposite pattern. For-profit hospitals are also more likely to adopt or discontinue services consistent with changes in service profitability than are nonprofits, which in turn are more likely to do so than government hospitals. These results are similar to those we found before passage of the Affordable Care Act, when many more patients were uninsured. Policy makers and researchers tend to focus on whether nonprofit hospitals provide sufficient free care to justify tax benefits, thereby overlooking the significance of ownership for service provision, which likely has critical health and spending consequences.

BackgroundPrivate hospitals expanded rapidly in China since 2009 following its national health reform encouraging private investment in the hospital sector. Despite long-standing debates over the performance of different types of hospitals, empirical evidence under the context of developing countries remains scant. We investigated the disparities in health care quality and medical expenses among public, private not-for-profit, and private for-profit hospitals.MethodsA total of 64,171 inpatients (51,933 for pneumonia (PNA), 9,022 for heart failure (HF) and 3,216 for acute myocardial infarction (AMI)) who were admitted to 528 secondary hospitals in Sichuan province, China, during the fourth quarters of 2016, 2017, and 2018 were selected for this study. Multilevel logistic regressions and multilevel linear regressions were utilized to assess the relationship between hospital ownership types and in-hospital mortality, as well as medical expenses for PNA, HF, and AMI, after adjusting for relevant hospital and patient characteristics, respectively.ResultsThe private not-for-profit (adjusted OR, 1.69; 95% CI, 1.08, 2.64) and for-profit (adjusted OR, 1.67; 95% CI, 1.06, 2.62) hospitals showed higher in-hospital mortality than the public ones for PNA, but not for AMI and HF. No significant differences were found in medical expenses across hospital ownership types for AMI, but the private not-for-profit was associated with 9% higher medical expenses for treating HF, while private not-for-profit and for-profit hospitals were associated with 10% and 11% higher medical expenses for treating PNA than the public hospitals. No differences were found between the private not-for-profit and private for-profit hospitals both in in-hospital mortality and medical expenses across the three conditions.ConclusionThe public hospitals had at least equal or even higher healthcare quality and lower medical expenses than the private ones in China, while private not-for-profit and for-profit hospitals had similar performances in these aspects. Our results added evidences on hospitals’ performances among different ownership types under China’s context, which has great potential to inform the optimization of healthcare systems implemented among developing countries confronted with similar challenges.