For-profit Providers Research Articles

Distinctions Between Non-profit, For-profit, and Public Providers: The Case of Multi-sector Rental Housing

Although various organizational forms are involved in the critically important role of providing rental housing, little is known about their potentially distinctive characteristics. Calling upon unique data collected from landlords and tenants of for-profit, non-profit, and public rental housing in Canada (N = 5624 units; N = 492 tenants), we explore shelter costs paid by tenants, quality, and unit accessibility. Findings point to some unique features based on provider type: non-profits have lower shelter costs than for-profit units, and for-profit and public status are associated with lower odds of accessibility. Limited differences are found related to housing quality.

U.S. Health Care in the Trump Era: A Data Update.

We present a summary of recent studies and data regarding the state of health and health care in the United States. Health care remains unaffordable to many Americans, including many with insurance. Health outcomes are stagnating or deteriorating. Police killings disproportionately target minority men. The search for profits from prescription drug companies, medical device firms, and for-profit medical providers places patients at risk. The public Medicare and Medicaid insurance programs, which increasingly subcontract with private managed care insurers, now account for the majority of private insurers' total business. Insurance firms continue to avoid unprofitable enrollees and impose a mounting bureaucratic burden on medical providers. Meanwhile, recent polls show mounting public support for single-payer national health insurance.

Rethinking relationships: clarity, contingency, and capabilities

Governments around the world have developed complex portfolios of relationships with other parties in order to carry out the various activities needed to govern. Reliance on the efforts of other parties has long been a feature of government activity, but in recent times governments worldwide have adopted contracting models to deliver outcomes to citizens and communities. This has especially been the case in their relationships with for-profit and nonprofit providers of public services. Despite the widespread use of contracting by government, how governments think about contracting is very narrow. Indeed, most government contracting models rely very heavily on a specific tool – outsourcing. This means that the practice of contracting is often very limited and reliant on a narrow set of tools and relationships. Such a narrow mindset shapes and frames relationships in such ways that governments will often fail to fulfill their aspirations in working with other parties. Adopting broader notions of relationships is important in moving beyond a fixation on tools. Such a shift in mindset, however, demands new ways of thinking about the various parties, relationships, and modes of working together. In turn, this would require very different sets of capabilities to effectively work together. In this article, I set out a much broader notion of relationships and explain what this means for the capabilities that governments need to manage much more complex portfolios. These capabilities extend beyond the skills of public servants, encompassing organizational and environmental factors. The end result being the need for governments to move toward broader, more strategic notions of relationships in order to deliver on the needs and aspirations of citizens and communities.

Private sector engagement and contributions to immunisation service delivery and coverage in Sudan

For more than two decades, the private sector in the Sudan (henceforth, Sudan), including non-governmental organisations and for-profit providers, has played a key role in delivering immunisation services, especially in...

Malaria, medicines and miles: A novel approach to measuring access to treatment from a household perspective

Nearly a decade after the adoption of confirmed diagnosis and artemisinin combination therapy (ACT) for the treatment of uncomplicated falciparum malaria, a large treatment gap persists. We describe a novel approach of combining data from households and the universe of treatment sources in their vicinities to produce nationally representative indicators of physical and financial access to malaria care from the household’s perspective in Benin, Nigeria, Uganda and Zambia. We compare differences in access across urban and rural areas, countries, and over time.In 2009, more urban households had a provider stocking ACT within 5 km than rural households. By 2012, this physical ACT access gap had largely been closed in Uganda, and progress had been made in Benin and Nigeria; but the gap persisted in Zambia. The private sector helped to fill this gap in rural areas. Improvements in Nigeria and Uganda were driven largely by increased ACT availability in licensed drug stores, and in Benin by increased availability in unregulated open-air market stalls. Free or subsidised ACT from public and non-profit facilities continued to be available to many households by 2012, but much less so in rural areas. Where private sector expansion increased physical access to ACT, these additional options were on average more expensive. Also by 2012, the majority of urban households in all four countries had access to a provider nearby offering malaria diagnostic services; however, this access remained low for rural households in Benin, Nigeria and Zambia.The methods developed in this study could improve how access to healthcare is measured in low- and middle-income country settings, particularly where private for-profit providers are an important source of care, and for conditions that may be treated by informal providers. The method could also lead to better explanations of the performance of complex interventions aiming to improve healthcare access.

Public-private partnerships in the Spanish National Health System: The reversion of the Alzira model

In the statutory Spanish National Health System (SNHS), the role of public provision is prominent. Nonetheless, since the inception of the SNHS, Regional Health Authorities have also purchased hospital care from private not-for-profit or for-profit providers, usually complementing public provision. Over the years, the autonomous community of Valencia has championed the use of Public Private Partnerships (PPP) in the form of administrative concessions (AC) awarded to private providers. In the La Ribera Health Department, which includes Alzira, the company Ribera Salud held the concession to provide hospital and primary care to the registered population since 1999 - and this became known as the Alzira model. In April 2018, when the administrative concession was expected to be renewed, Valencia's Health Authority decided to terminate the concession and to revert to direct public provision. While most stakeholders - and in particular the left-wing regional government - were in favour of reverting to public provision, advocates of the Alzira model argued that it was superior in terms of productivity, per capita expenditure and quality. The termination of the Alzira model led to further regulatory changes enacted in the Law for Health 8/2018, which clearly states that public provision is the preferred model of service delivery and new (tighter) requirements are defined for any future PPPs aiming to settle in the autonomous community of Valencia. This paper describes the process and provides background information to understand the underlying reasons of this policy development.

Does sector matter for the quality of care services? A secondary analysis of social care services regulated by the Care Inspectorate in Scotland

ObjectivesSocial services are increasingly commissioned to third and for-profit sector providers, but little is known about whether and how these changes influence quality indicators. We assessed quality-related outcomes across for-profit,...

Regional governance arrangements of the Brazilian Unified National Health System: provider diversity and spacial inequality in service provision.

The study analyzes regional Brazilian Unified National Health System (SUS, in Portuguese) governance arrangements according to providers' legal sphere and the spacial provision of middle and high-complexity services. These arrangements express the way in which State and health system reforms promoted the redistribution of functions between governmental and private entities in the territory. We carried out an exploratory study based on national-scope secondary data from 2015-2016. Using cluster analysis based on the composition of the provision percentages of the main providers, we classified 438 health regions. In middle-complexity health care, municipal public providers (outpatient) and private philanthropic providers (hospital) predominate. In high complexity provision, philanthropic and for-profit providers (outpatient and hospital) predominate. Middle-complexity provision was recorded in all health regions. However, in 12 states, more than half of the provision is concentrated in only one health region. High-complexity provision is concentrated in state capital regions. Governance arrangements may be more or less diverse and unequal, if different segments and regional concentration levels of middle and high-complexity provision are considered. The study suggests that the convergence between decentralization and mercantilization favored re-scaling of service provision, with increase in the scale of participation of private providers and strengthening of reference municipalities. Governance arrangement characteristics challenge SUS regionalization guided by the collective needs of the population.

How Does For-Profit College Attendance Affect Student Loans, Defaults and Labor Market Outcomes?

For-profit providers are becoming an increasingly important fixture of US higher education markets. Students who attend for-profit institutions take on more educational debt, have worse labor market outcomes, and are more likely to default than students attending similarly-selective public schools. Because for-profits tend to serve students from more disadvantaged backgrounds, it is important to isolate the causal effect of for-profit enrollment on educational and labor market outcomes. We approach this problem using a novel instrument combined with more comprehensive data on student outcomes than has been employed in prior research. Our instrument leverages the interaction between changes in the demand for college due to labor demand shocks and the local supply of for-profit schools. We compare enrollment and postsecondary outcome changes across areas that experience similar labor demand shocks but that have different latent supply of for-profit institutions. The first-stage estimates show that students are much more likely to enroll in a for-profit institution for a given labor demand change when there is a higher supply of such schools in the base period. Among four-year students, for-profit enrollment leads to more loans, higher loan amounts, an increased likelihood of borrowing, an increased risk of default and worse labor market outcomes. Two-year for-profit students also take out more loans, have higher default rates and lower earnings. But, they are more likely to graduate and to earn over $25,000 per year (the median earnings of high school graduates). Finally, we show that for-profit entry and exit decisions are at most weakly responsive to labor demand shocks. Our results point to low returns to for-profit enrollment that have important implications for public investments in higher education as well as how students make postsecondary choices.

Selling the American Dream: What the Trump University Scam Teaches Us about Predatory Colleges

Selling the American Dream:What the Trump University Scam Teaches Us about Predatory Colleges Robert Shireman (bio) classic scams usually revolve around products that are difficult for consumers to assess: the effectiveness of a medical procedure or drug; the integrity of an investment vehicle; the value of a gemstone; the authenticity of a work of art or historical artifact. Frequently, outright deception is not necessary for a con to be successful, because marketers have become experts in crafting sales pitches that play on "modern enticements and anxieties," creating messages that are misleading but without a stated untruth (Balleisen 2017, 174). Since the consumers seem to make their choices voluntarily, holding "unrealistic hopes for profit, cure, and inexpensive quality," the sellers, even though they have an informational advantage, are frequently not held responsible for bad outcomes for the consumer (Braucher and Orbach 2015, 250). Nowhere is the danger of scams greater than in education. Advancing one's education is widely seen as a wise investment, even for buyers without disposable income. Taking out loans to pay for an education can be portrayed by the seller as a wiser choice than buying a car, because the car depreciates while an education yields returns for a lifetime. The buyer, meanwhile, has a role not only in choosing the education but also in attending, studying, and then seeking a job. [End Page 767] As a result, a scam school has multiple ways to portray any bad out-come—dropouts, joblessness, loan defaults—as the fault of the student rather than the school. Education exhibits a type of market failure that Yale law professor Henry Hansmann, in a seminal article, called "contract failure." When it is difficult to evaluate the quality of a promised or provided product or service, the provider can too easily overcharge or deliver inferior goods (Hansmann 1980, 845). Consumers in these circum-stances may not realize they did not get their money's worth until many years later, if ever. And it is extremely difficult to craft a contract that ensures that every aspect of the product will be delivered as the consumer expects. These "trust markets" are frequently where nonprofit entities emerge as preferred providers (Winston 1999, 14). For-profit providers in such markets find themselves in need of a way to convince consumers that they can be trusted. That signal may take the form of their institution being eligible to accept federal financial aid—or, as in the case of Trump University, the signal may be the nameplate of a prominent business figure. TRUMP UNIVERSITY SETS UP SHOP On a cold Thursday evening in March 2009, 40 local residents showed up at the Doubletree Hotel in Somerset, New Jersey, for a free introductory class sponsored by Trump University. Capitalizing on the hit television show The Apprentice, the 90-minute "Apprenticeship Workshops," held regularly across the country since 2007, were promoted in ads featuring a smiling Donald with the blaring headline, "Are YOU the next DONALD TRUMP? Come prove it to me!" (People v. Trump Entrepreneur Initiative LLC, Affirmation of Asst. Att'y Gen. Snell 2014, Ex. M2, 000388; hereafter Snell Affirmation). From the moment they walked in the door, the participants were scrutinized by a sales team trained to find ways to "set the hook" for a later sale. "Let them know that you've found an answer to their problems and a way for them to change their lifestyle," the salespeople were instructed. "Collect personalized information that [End Page 768] you can utilize during closing time," for example, "are they a single parent of three children that may need money for food? … [T]he more it hurts, the more they'll be prepared to pay for a speedy solution" (Trump University 2010, 19-20, 100, 104). The school's operations manual, unselfconsciously labeled the "Playbook" (Trump University 2010), assumed that potential customers would be skeptical. After all, the economy was in freefall due in part to mortgage scandals, and Bernie Madoff's arrest the prior December for an epic investment fraud was still fresh in the news. To "disarm any uncertainty," salespeople were told to be friendly and engaging during the registration process, taking care to keep the...

Evidence-based treatment for opioid use disorders: A national study of methadone dose levels, 2011–2017

The nation's methadone maintenance treatment (MMT) programs play a central role in addressing the current opioid epidemic. Considerable evidence documents the treatment effectiveness of MMT and, in turn, the importance of adequate dosing to MMT's effectiveness. Yet, as recently as 2011, 41% of patients received doses below the level of 80 mg/day. Using survey data from a nationally representative sample of MMT programs in 2011 and 2017, we examine (1) the extent to which the nation's MMT programs are meeting evidence-based standards for methadone dose level and (2) characteristics of MMT programs that are associated with variation in performance. Our results show that 43% of MMT patients receive <80 mg/day in 2017, and 23% of methadone maintenance patients receive daily doses below 60 mg. Results from multivariate regression analysis of the 2017 survey data show that private for-profit and public organizations significantly under-dosed patients compared to private nonprofit providers. Under-dosing also was more common in programs that serve high proportions of African-American patients. These results are concerning because MMT remains the medication of choice for vulnerable patients with the most severe opioid use disorders, and for-profit providers treat a growing proportion of MMT patients.

Better together: Coexistence of for-profit and nonprofit firms with an application to the U.S. hospice industry

Many markets maintain a nontrivial mix of both nonprofit and for-profit firms, particularly in health care industries such as hospice, nursing homes, and home health. What are the effects of coexistence vs. dominance of one ownership type? We show how the presence of both ownership types can lead to greater diversity in consumer types served, even if both firms merely profit-maximize. This is the case where firms serve consumers for multiple consumption durations, but where donations are part of a nonprofit firm objective function and happen after services have been provided. This finding is strengthened if the good or service has value beyond immediate consumption or the direct consumer. We show these predictions empirically in the hospice industry, using data containing over 90 percent of freestanding U.S. hospices, 2000–2008. Nonprofit and for-profit providers split the patient market according to length of stay, leading to a wider range of patients being served than in the absence of this coexistence.

Public/private ownership and quality of care: Evidence from Danish nursing homes

The involvement of private for-profit (FP) and not-for-profit (NFP) providers in the otherwise public delivery of welfare services is gradually changing the Nordic welfare state towards a more market-oriented mode of service delivery. This article examines the relationship between ownership and quality of care in public and private FP and NFP nursing homes in Denmark. The analysis draws on original survey data and administrative registry data (quality inspection reports) for the full population of almost 1000 nursing homes in Denmark. Quality is measured in terms of structural quality, process quality and outcome quality. We find that public nursing homes have a higher structural quality (in terms of, for instance, staffing), while FP providers perform better in terms of process quality (e.g. in the form of individualised care). NFP providers perform well in terms of structural criteria such as employment of full-time staff and receive fewer critical comments in the inspection reports. However, the results depend to some extent upon the method of data collection, which underlines the benefits of using multiple data sources to examine the relationship between ownership and the quality of care.

Does Ownership Matter in the Selection of Service Providers? Evidence From Nursing Home Consumer Surveys

This study considers the role of ownership in consumer choice of service providers in mixed-ownership industries. First, it analyzes theoretically consumer search in the face of severe asymmetric information about important service attributes in a market where nonprofit, for-profit, and local government providers coexist. Second, the article distinguishes between two consumer decision strategies, traditional search for information, and using ownership as a signal of quality. Third, the article analyzes an original data set about nursing homes and their customers (residents and their families). We found that (a) despite empirical evidence showing that nonprofit nursing homes are of higher quality, consumers who use ownership status in their search were more likely to choose for-profit organizations; (b) better educated consumers are more likely to choose nonprofit over for-profit organizations; (c) consumers who search more in-depth and who find information about nursing home lobbies less important for selection are more likely to choose homes that are nonprofit. The choice of local government–owned homes is based on a process that resembles weakly the process used to choose nonprofit homes more than for-profit homes.

Do long-term care services match population needs? A spatial analysis of nursing homes in Chile.

Chile is experiencing a period of rapid aging, which increases the need of long-term care services in the country. Nursing homes have been the traditional alternative to deal with the increase of elderly population in the country, with services supplied by a mix of for-profit and nonprofit providers. Additionally, population exhibits a high degree of geographical concentration. The study aims to identify the determinants of the geographical location of nursing homes in Chile at municipality level. The analysis takes into account the different location criteria for different types of nursing homes as well as potential spatial effects. The paper uses spatial analysis tools to identify clusters of nursing homes and population characteristics and to estimate the determinants of nursing homes availability and coverage in the country. The analysis–based on spatial global and local tests, and spatial autoregressive models- show the existence of clusters of nursing homes as well as clusters of municipalities according to elderly population, income, poverty, population density, and public health insurance coverage. Residuals from ordinary least squares regressions were spatially autocorrelated, showing the need of using spatial models. Estimations show that availability and coverage of nursing homes are positively related with municipality income, and that for-profit and nonprofit facilities respond differently to different factors. A negative coefficient was found for poverty in nonprofit nursing homes, raising doubts about the effectiveness of giving public subsidies to incentive the installation of facilities in areas with high needs and low income.

Competition in public service provision: The role of not-for-profit providers

With public services such as health and education, it is not straightforward for consumers to assess the quality of provision. Many such services are provided by monopoly not-for-profit providers and there is concern that for-profit providers may increase profit at the expense of quality. This paper explores the implications of entry by for-profit providers when there is unobserved quality. The model generates three key policy-relevant insights. First, by developing a novel approach to competition between different organizational forms, it frames the relevant trade-offs precisely. Second, it shows the value of keeping an incumbent not-for-profit as an active provider. Third, it characterizes the optimal payment (or voucher value) to an entrant for each consumer who switches in a way that can be applied empirically.

Technical quality of delivery care in private- and public-sector health facilities in Enugu and Lagos States, Nigeria.

Private-sector providers are increasingly being recognized as important contributors to the delivery of healthcare. Countries with high disease burdens and limited public-sector resources are considering using the private sector to achieve universal health coverage. However, evidence for the technical quality of private-sector care is lacking. This study assesses the technical quality of maternal healthcare during delivery in public- and private-sector facilities in resource-limited settings, from a systems and programmatic perspective. A summary index (the skilled attendance index, SAI), was used. Two-staged cluster sampling with stratification was used to select representative samples of case records in public- and private-sector facilities in Enugu and Lagos States, Nigeria. Information to assess criteria was extracted, and the SAI calculated. Linear regression models examined the relationship between SAI and the private and public sectors, controlling for confounders. The median SAI was 54.8% in Enugu and 85.7% in Lagos. The private for-profit sector's SAI was lower than and the private not-for-profit sector's SAI was higher than the public sector in Enugu [coefficient = -3.6 (P = 0.018) and 12.6 (P < 0.001), respectively]. In Lagos, the private for-profit sector's SAI was higher and the private not-for-profit sector's SAI was lower than the public sector [3.71 (P = 0.005) and -3.92 (P < 0.001)]. Results indicate that the technical quality of private for-profit providers' care was poorer than public providers where the public provision of care was weak, while private for-profit facilities provided better technical quality care than public facilities where the public sector was strong and there was a relatively strong regulatory body. Our findings raise important considerations relating to the quality of maternity care, the public-private mix and needs for regulation in global efforts to achieve universal healthcare.

Linking private, for-profit providers to public sector services for HIV and tuberculosis co-infected patients: A systematic review.

BackgroundTuberculosis (TB) is the leading cause of infectious disease deaths worldwide and is the leading cause of death among people with HIV. The World Health Organization (WHO) has called for collaboration between public and private healthcare providers to maximize integration of TB/HIV services and minimize costs. We systematically reviewed published models of public-private sector diagnostic and referral services for TB/HIV co-infected patients.MethodsWe searched PubMed, the Cochrane Central Register of Controlled Trials, Google Scholar, Science Direct, CINAHL and Web of Science. We included studies that discussed programs that linked private and public providers for TB/HIV concurrent diagnostic and referral services and used Review Manager (Version 5.3, 2015) for meta-analysis.ResultsWe found 1,218 unduplicated potentially relevant articles and abstracts; three met our eligibility criteria. All three described public-private TB/HIV diagnostic/referral services with varying degrees of integration. In Kenya private practitioners were able to test for both TB and HIV and offer state-subsidized TB medication, but they could not provide state-subsidized antiretroviral therapy (ART) to co-infected patients. In India private practitioners not contractually engaged with the public sector offered TB/HIV services inconsistently and on a subjective basis. Those partnered with the state, however, could test for both TB and HIV and offer state-subsidized medications. In Nigeria some private providers had access to both state-subsidized medications and diagnostic tests; others required patients to pay out-of-pocket for testing and/or treatment. In a meta-analysis of the two quantitative reports, TB patients who sought care in the public sector were almost twice as likely to have been tested for HIV than TB patients who sought care in the private sector (risk ratio [RR] 1.98, 95% confidence interval [CI] 1.88–2.08). However, HIV-infected TB patients who sought care in the public sector were marginally less likely to initiate ART than TB patients who sought care from private providers (RR 0.89, 95% CI 0.78–1.03).ConclusionThese three studies are examples of public-private TB/HIV service delivery and can potentially serve as models for integrated TB/HIV care systems. Successful public-private diagnostic and treatment services can both improve outcomes and decrease costs for patients co-infected with HIV and TB.

Discrimination and Administrative Burden in Public Service Markets: Does a Public–Private Difference Exist?

Public services are often provided in markets where both public and private providers operate. Irrespective of ownership status, public services ought to be accessible regardless of clients’ race, gender, ethnicity, or age. However, as theories of statistical discrimination and cream skimming suggest, market-based incentives may lead service providers to focus on non-minority clients because they perceive them as easier-to-serve and therefore less costly. This may lead to discrimination and hence jeopardizes equal access. In this study, we ask whether private, for-profit providers are more likely to discriminate on ethnic grounds compared to publicly owned providers. We implement a field experiment within the Flemish elderly care market by sending out email requests with either a Flemish or a Maghrebian name to all public and privately owned nursing homes. For overall response rates, no statistically significant differences between senders were found. However, we do find that privately owned facilities are about 20 percentage points less likely to provide information on how to enroll when the request is send from a Maghrebian name alias, and blinded coders perceive the information sent to the Maghrebian alias as less comprehensive. In publicly owned facilities, no such differences exist. We conclude that a public-private difference does exist, but that the mechanism of discrimination is subtler than expected. Rather than directly refusing to respond, nursing homes increase administrative burdens and learning costs for minority applicants.

Employee representation and pension fund governance in Australia

Representative arrangements are widely employed in the governance of occupational pension funds, particularly in Australia where a sector of jointly employer/employee-sponsored ‘industry funds’ was established during the 1980s. The jointly governed industry funds are privately owned wealth-management businesses and have routinely outperformed the retirement-savings schemes run by the large listed for-profit providers. Seeking to understand why these examples of labourist ‘alternative organisations’ have outperformed more traditionally governed Australian wealth-management firms is the main purpose of this article.