For-profit System Research Articles

Keep your head above water: Explaining disparities in local drinking water bills

Rising water bills across the U.S. underscore the need to understand the factors that contribute to disparities in local system bills. In this paper, we examine residential water bill amounts from 1,720 systems in four states in different regions of the U.S. (Arizona, Georgia, New Hampshire and Wisconsin) to (1) examine how local system bills at a constant consumption level (4,000 gallons per month or 15.14m3) for drinking water vary within and across states, as well as within combined metropolitan statistical areas (MSAs), and (2) study the relationship between local system bills and system-level characteristics. We find a high degree of similarity in median bill amounts between states but substantial variation within them at the MSA and local system scale. Our multivariate analysis suggests that municipally-owned systems are more likely to have lower water bills relative to for-profit systems, while factors such as purchasing water and having neighboring systems with high bills significantly correlate with higher water bills. Though we find that water systems with high levels of poverty tend to have higher water bills, our results also suggest that local systems that serve populations with higher levels of income inequality and higher proportions of non-White population tend to have lower water bills. These findings point to future research and data needs to better inform federal, state and local water affordability policy and underline the importance of examining and addressing water affordability at local scales.

Measuring the Monetary Value of Online Volunteer Work

Online volunteers are a crucial labor force that keeps many for-profit systems afloat (e.g. social media platforms and online review sites). Despite their substantial role in upholding highly valuable technological systems, online volunteers have no way of knowing the value of their work. This paper uses content moderation as a case study and measures its monetary value to make apparent volunteer labor’s value. Using a novel dataset of private logs generated by moderators, we use linear mixed-effect regression and estimate that Reddit moderators worked a minimum of 466 hours per day in 2020. These hours are worth 3.4 million USD based on the median hourly wage for comparable content moderation services in the U.S. We discuss how this information may inform pathways to alleviate the one-sided relationship between technology companies and online volunteers.

The problems of social care in English nursing and residential homes for older people and the role of state regulation

ABSTRACT The problems facing English care homes for older people have largely been defined in terms of funding. This paper starts from the position that it is vitally important also to address the big issue of the social care system, especially the changing nature of private provision since the introduction of a quasi-market almost three decades ago, such that large corporations have become increasingly dominant. The paper focuses on the implications of a fragmented, for-profit system of provision for financial sustainability and care quality, particularly in terms of workforce issues. It argues that heavy reliance on regulation via the market and operating through competition and choice is misplaced and that state regulation can play a crucial part in securing improvement in these fields. It concludes that the Government’s recent (2021) proposals, which are mainly confined to funding and designed to prop up the current system, are unlikely to provide the ‘long-term fix’ that social care needs.

Hospital Ownership and Financial Stability: A Matched Case Comparison of a Nonprofit Health System and a Private Equity-Owned Health System.

The long-term financial stability of hospital systems represents a "grand challenge" in health care. New ownership forms, such as private equity (PE), promise to achieve better financial performance than nonprofit or for-profit systems. In this study, we compare two systems with many similarities, but radically different ownership structures, missions, governance, and merger and acquisition (M&A) strategies. Both were nonprofit, religious systems serving low-income communities - Montefiore Health System and Caritas Christi Health Care. Montefiore's M&A strategy was to invest in local hospitals and create an integrated regional system, increasing revenues by adding primary doctors and community hospitals as feeders into the system and achieving efficiencies through effective resource allocation across specialized units. Slow and steady timing of acquisitions allowed for organizational learning and balancing of debt and equity. By 2019, it owned 11 hospitals with 40,000 employees and had strong positive financials and low reliance on debt. By contrast, in 2010, PE firm Cerberus Capital bought out Caritas (renamed Steward Health Care System) and took control of the Board of Directors, who set the system's strategic direction. Cerberus used Steward as a platform for a massive debt-driven acquisition strategy. In 2016, it sold off most of its hospitals' property for $1.25 billion, leaving hospitals saddled with long-term inflated leases; paid itself almost $500 million in dividends; and used the rest for leveraged buyouts of 27 hospitals in 9 states in 3 years. The rapid, scattershot M&A strategy was designed to create a large corporation that could be sold off in five years for financial gain - not for health care integration. Its debt load exploded, and by 2019, its financials were deeply in the red. Its Massachusetts hospitals were the worst financial performers of any system in the state. Cerberus exited Steward in 2020 in a deal that left its physicians, the new owners, holding the debt.

The Changing Landscape of Catholic Hospitals and Health Systems, 2008-2017.

More than 600 Catholic hospitals operating in the United States face pressures for efficiency and effectiveness as well as compliance with demands of the Roman Catholic Church. They have responded to the pressures in various ways that have led to mixed models of organizational ownership and management. The purpose of this study was to describe and analyze the status of Catholic hospital ownership and management, especially the strategic and structural features of the parent health systems. Longitudinal data (2008-2017) were acquired and analyzed using repeated-measures analysis. Descriptive statistics were prepared using cross-sectional matched pairing for 2008 and 2017 data. Of 4,253 hospitals studied, 534 changed ownership or management. More Catholic Church-operated hospitals, regardless of type of ownership (for-profit, not-for-profit, church), became decentralized to a greater degree over the 8-year period and took on more attributes of non-Catholic hospitals.The 21st century Catholic hospital is more likely to be partnered with a non-Catholic hospital or to be owned by a for-profit system than to be solely partnered with or operated by another Catholic system. Today's Catholic hospitals appear to be more similar to their non-Catholic counterparts. With the trend toward larger systems that comprise more diverse partners, an increase in lay oversight could lead to further movement away from Catholic identity and the original mission of a hospital. As systems grow in size but shrink in number, administrators must make difficult decisions about the type and scope of services offered as well as the partners they need to deliver their services.

Open access: uma tentativa de ruptura de paradigma

O presente estudo tem por objetivo apresentar um panorama histórico e comportamental dos agentes do mercado de publicação científica. Através das referências teóricas das Tragédias dos Comuns e Anticomuns, bem como da Ação Coletiva, o trabalho analisa os dois nichos que divide o mercado estudado: sistema comercial de repositórios restritos e o sistema de repositórios digitais abertos. O meio tradicional de publicação de conteúdos consiste em um sistema com fins lucrativos, dirigido por editoras comerciais as quais adquirem receitas através da taxação por acesso de artigos publicados. Devido à restrição orçamentária de diversas instituições fomentadoras de pesquisas, junto à ideologia de democratização da informação, surgiu um movimento paralelo de publicação científica que foca no livre acesso aos conteúdos publicados. O conflito existente entre os dois nichos, caracteriza a complexidade desse segmento de publicação científica, ao mesmo tempo que divide opiniões e decisões de pesquisadores das comunidades acadêmicas ao redor do mundo. O estudo conclui que o acesso aberto como um sistema concorrente ao mercado das editoras comerciais, embora possua avanços a passos consideráveis, ainda não possui força suficiente para romper com o paradigma atual.

The many roads to universal health care in the USA

Health-care systems in different countries have evolved along different paths, with some countries offering private insurance, some universal health care, and some a mixture between the two. In most high-income countries, health care is considered a human right and is provided universally, typically free at the point-of-care. The USA has developed a fractured for-profit system that is substantially more expensive than those of its European counterparts and delivers poorer outcomes than the health-care systems in other high-income countries, while leaving a substantial proportion of Americans without health coverage. This Personal View discusses the current health-care system in the USA and offers a roadmap towards the achievement of universal health care for the USA. Three key components of the roadmap are: support and improve the Affordable Care Act; maintain the existing private insurance system; offer in parallel a government-sponsored health-care insurance, or gradually expand Medicare to more people, and ultimately to all Americans not covered under existing health-care insurances.

Can economic incentives increase the use of home dialysis?

There are advantages to home dialysis for patients, and kidney care programs, but use remains low in most countries. Health-care policy-makers have many levers to increase use of home dialysis, one of them being economic incentives. These include how health-care funding is provided to kidney care programs and dialysis facilities; how physicians are remunerated for care of home dialysis patients; and financial incentives-or removal of disincentives-for home dialysis patients. This report is based on a comprehensive literature review summarizing the impact of economic incentives for home dialysis and a workshop that brought together an international group of policy-makers, health economists and home dialysis experts to discuss how economic incentives (or removal of economic disincentives) might be used to increase the use of home dialysis. The results of the literature review and the consensus of workshop participants were that financial incentives to dialysis facilities for home dialysis (for instance, through activity-based funding), particularly in for-profit systems, could lead to a small increase in use of home dialysis. The evidence was less clear on the impact of economic incentives for nephrologists, and participants felt this was less important than a nephrologist workforce in support of home dialysis. Workshop participants felt that patient-borne costs experienced by home dialysis patients were unjust and inequitable, though participants noted that there was no evidence that decreasing patient-borne costs would increase use of home dialysis, even among low-income patients. The use of financial incentives for home dialysis-whether directed at dialysis facilities, nephrologists or patients-is only one part of a high-performing system that seeks to increase use of home dialysis.

Criminal Justice, Inc.

In the past decade, major retailers nationwide have begun to employ a private, for-profit system to settle criminal disputes, extracting payment from shoplifting suspects in exchange for a promise not to call the police. This Article examines what retailers’ decisions reveal about our public system of criminal justice and the concerns of the agents who run it, the victims who rely on it, and the suspects whose lives it alters. The private policing of commercial spaces is well known, as is private incarceration of convicted offenders. This Article is the first, however, to document how industry has penetrated new parts of the criminal process, administering sanctions to resolve thousands of shoplifting allegations each year. Proponents of private justice claim that everyone wins. Critics say it’s blackmail. The Article takes a tentative middle ground: While “retail justice” is not the American ideal, it may nonetheless be preferable to public criminal justice, at least if certain conditions are met. Rather than cancel the private justice experiment, therefore, as several states are poised to do, the government should aim to foster optimal conditions for its success. Extending the central analysis, the Article then shows how the study of private justice leads to fresh perspectives on important criminal justice issues. It suggests, for example, that the costs to crime victims of assisting the prosecution may be a feature of the system, not a bug, if they encourage victims to invest in efficient crime-deterring precautions. It also complicates legal academic models of police and prosecutorial behavior built on maximizing arrests and convictions. The Article concludes by identifying conditions that conduce to private criminal justice and speculating about the next frontiers.

After-action review of the 2009-10 H1N1 Influenza Outbreak Response: Ohio's Public Health System's performance.

In early 2009, H1N1 influenza was identified within the human population. Centers for Disease Control and Prevention (CDC) officials responded with focused assessment, policy development, and assurances. The response was mobilized through efforts including procurement of adequate vaccine supply, local area span of control, materials acquisition, and facilities and resource identification. Qualitative evaluation of the assurance functions specific to the system's ability to assure safe and healthy conditions are reported. The methodology mirrors the Homeland Security Exercise and Evaluation Program used to assess system capability. Findings demonstrate the effectiveness of community responsive disease prevention efforts in partnership with the public health systems mission to unify traditional public sector systems, for-profit systems, and local area systems was accomplished. As a result of this response pharmaceutical industries, healthcare providers, healthcare agencies, police/safety, colleges, and health and human service agencies were united. Findings demonstrate the effectiveness of community response strategies utilizing feedback from system stakeholders. After-action review processes are critical in all-hazards preparedness. This analysis of local health district response to the H1N1 influenza outbreak informs future public health service delivery. Results provide a synthesis of local health department's emergency response strategies, challenges encountered, and future-focused emergency response strategy implementation. A synthesis is provided as to policy and practice developments which have emerged over the past seven years with regard to lessons learned from the 2009-10 H1N1 influenza outbreak and response.

A practical framework for regulating for-profit recreational marijuana in US States: Lessons from Colorado and Washington

Despite the federal prohibition against marijuana, state-level recreational use appears to be moving forward. Public opinion is shifting. Following well-publicized state-legalization in Washington and Colorado, states across the US have begun considering similar measures. Since the 2016 election, over 21% of Americans now live in places where recreational marijuana is state-legal, and over 63% of the country permits medical or recreational use at the state level. This paper does not consider whether states should legalize marijuana nor does it weigh all regulatory options available to states. Instead, it considers how states can create a practical framework to regulate recreational marijuana, particularly in a climate of federal uncertainty where marijuana remains illegal. We draw lessons from Colorado and Washington—assuming that other states will adopt similar models and employ commercial, for-profit systems. Considering both the variety of goals that states could adopt and how they interact, we offer recommendations in five areas: cultivation, production, and processing; sale, consumption, and possession; taxes and finance; public health and safety; and governance. We recommend that states implement a relatively restrictive regulatory approach, with a single market for recreational and medical marijuana, if appropriate. This should make marijuana laws easier to enforce, help reduce diversion, and satisfy federal guidance. Moreover, drawing from Colorado and Washington’s experience, we suggest a flexible system with robust data collection and performance monitoring that supports a thorough evaluation. This should allow states to “learn as they go”—a must, given the uncertainty surrounding such policy shifts. Of course, a tightly regulated approach will have drawbacks—including a significant illegal market. But political experience teaches that states will be better off loosening a tight market than attempting to tighten a loose one. We also consider a potential role for the federal government under the status quo.

Meta-Kucha: The margin or the mainstream?

The inexorable push in integrated care is to move collaboration between biomedical and psychosocial clinicians into the mainstream of health care. This effort requires expanding small models to scale, convening statewide transformation initiatives, and leaving the comfortable confines of safety net clinics to prove integration in the for-profit systems that dominate American health care. CFHA's (Collaborative Family Health care Association's) Pecha Kucha Plenary assembled compelling narratives from the fringes of our health care system. The competing calls from the mainstream and from the margins force tension into our dialogue. However, for our model to be widely embraced, we need blueprints that fit most patients in most clinics. What we learned from the Pecha Kucha narratives is that people at the margins find ways of asserting their voices and achieving their needs. Sometimes it is through their own resilience and disruptiveness; other times it is through an advocate from the mainstream who shares their stories in such a compelling way that they bypass our well-crafted models and spark our souls.

Partnering for More Than the Survival of a Catholic Presence in Healthcare

One of the contributions to the Catholic healthcare ministry made by the late Cardinal Bernardin is a set of criteria for Catholic healthcare systems to use in choosing partners for joint ventures and affiliations (Bernardin, 1994). He based his criteria on the premise that appropriate partners are those who will ultimately strengthen and enhance the Catholic presence in healthcare in general, and the Catholic identity of the Catholic facility in particular. Hence, the preferred partner is another Catholic party. A second option is another not-for-profit system or facility that shares “in a substantive way our Catholic vision and values.” This choice of partner can be problematic in that, even if common vision and values are affirmed, the Catholic identity of the Catholic partner may be diluted. This situation could occur, for example, as a result of the shift from an exclusive Catholic sponsorship to an arrangement of co-sponsorship. It could also result from the need, in some cases at least, for material cooperation by the Catholic system in some prohibited procedures. The growing reluctance in some quarters to approve material cooperation even for the sake of a continued Catholic presence in healthcare (e.g., Smith, 1996) makes such partnerships especially troublesome. In addition to diluting the identity of the Catholic partner, choosing non-Catholic partners may, in some instances, damage the presence of Catholic healthcare by putting other Catholic facilities in the same service area at financial risk. A third partner option is a for-profit system. For-profit healthcare had been judged by the Cardinal to be inimical to Catholic identity, and is ruled out (Bernardin, 1995; Place, 1998). These criteria have proven to be helpful. They are helpful, however, only within the limited context of their grounding premise: the need to preserve and promote Catholic healthcare’s ministry. The “healthcare” ministry is not the only public ministry of the Church. Nor does the healing ministry of the Church need to be viewed solely as an end, sought for its own sake. It is also possible and legitimate to view the healthcare ministry as a vehicle through which to pursue or fulfill another Church ministry. The criteria for choosing partners in healthcare can also be premised on a desire to strengthen and preserve a different public ministry of the Church. At the very least, this could allow choices of partners being made with more enthusiasm and creativity

Experiences of the Electricity System Operator Incentive Scheme in Great Britain

National Grid is the electricity system operator in Great Britain and has an unique feature in so far as it is one of the world’s few for-profit system operators. In addition, the commercially orientation of the British market rules means that nearly every action taken by National Grid to operate the system has a cost associated to it. Based on those factors and in order to encourage National Grid to seek continuous improvements and drive for efficient and economic system operation, the regulator (Ofgem) offers an incentive scheme, whereby a target is agreed annually and any savings in relation to this target are shared between consumers and National Grid in the form of a profit. It is in National Grid’s best interest to have mechanisms to mitigate the impacts of volatility in the costs it faces as system operator so that it can implement cost saving actions without the risk of windfall losses (or gains) arising from sudden changes in uncontrollable drivers. The purpose of this paper is to share the experiences of National Grid in the operation of Great Britain's electricity system, with a special interest on the mechanisms created to manage the associated costs in response to the incentive scheme. It does so by describing the market operation in Great Britain and the costs drivers impacting National Grid’s system operation and illustrating the steps recently taken by National Grid to propose volatility mitigation mechanisms. It concludes with the rationale and expected results from the latest proposals as consulted with the industry for introduction in the incentive scheme starting on 1st April 2011. It is worth noting that with this work, the authors wish to both share the experience with other system operators and regulators in the world, as well as give British market participants an insight on the inner workings of National Grid.

HealthSouth's Inpatient Rehabilitation Facilities: How Does Their Performance Compare With Other For-Profit and Nonprofit Inpatient Rehabilitation Facilities?

McCue MJ, Thompson JM. HealthSouth's inpatient rehabilitation facilities: how does their performance compare with other for-profit and nonprofit inpatient rehabilitation facilities? Objectives To assess the financial and operational differences in freestanding inpatient rehabilitation facilities (IRFs) that are operated by HealthSouth Corporation relative to other for-profit and nonprofit system-affiliated ownership groups. Since 2003, when it faced fraud charges and financial penalties, HealthSouth has experienced new management and refocused its business strategy. Because HealthSouth is the largest provider of freestanding IRF services, it is important to understand how their performance may differ relative to other ownership groups. Design We used the Mann-Whitney U test to assess differences in median values for financial and operational variables of HealthSouth-owned IRFs compared with other for-profit system IRFs and nonprofit system IRFs. Setting System-affiliated freestanding IRFs in the United States. Participants Sixty-four HealthSouth IRFs, 18 nonprofit system-affiliated IRFs, and 18 for-profit system-affiliated IRFs. Interventions Not applicable. Main Outcome Measures Net patient revenue per adjusted discharge, operating expense per adjusted discharge, salary expense per full-time equivalent, and cash flow margin. Results HealthSouth IRFs had significantly lower net patient revenue per adjusted discharge and operating expense per adjusted discharge; however, its cash flow margin was significantly higher than other comparison groups. HealthSouth IRFs treated a higher case mix of patients relative to these comparison groups. Conclusions The financial and operating performance of HealthSouth IRFs is stronger than other ownership groups. Strong cash flow will enable HealthSouth to pay down long-term debt.

Nurse staffing and hospital ownership in California.

The purpose of this study is to describe the relationship between nurse staffing and owner type or specific corporate owner in California acute care hospitals. Little empirical data exist regarding nurse staffing as it relates to owner type or specific corporate owner. With minimum staffing ratios scheduled to be implemented in January 2004, this study provides baseline data for evaluating the impact of minimum staffing ratios in California. The study design is descriptive and cross-sectional. Data used in this study are for short-term general hospitals that reported to the California Office of Statewide Health Planning and Development database for fiscal years ending in 1997 through 1999. Six regression models were estimated using pooled data from the 3 years of data. The most consistent significant findings are: increased patient days or patient discharges predict increased registered nurse (RN) hours; lower RN wages predict increased RN hours; higher technology scores predict increased RN hours; and in 1998 there was an across-the-board decrease in RN hours. Other significant findings include that for-profit hospitals and for-profit systems had fewer RN productive hours for medical-surgical nursing, and select corporate owners, unrelated to profit status, had consistently fewer RN productive hours for medical-surgical nursing. For-profit hospitals and systems behaved differently in the healthcare market environment of the late 1990s. Select nonprofit systems were also using significantly less RN staffing. Other findings support the implication that as technology sophistication increases, there will be a need for increased RN hours to manage the advanced technology. This runs counter to the argument that increasing technology will decrease the need for RN hours. Finally, as discharges go up, the need for RN hours increases.

Trends in hospital consolidation: the formation of local systems.

During the past decade the hospital industry has made profound organizational changes, including the extensive consolidation of hospitals through merger and the formation of hospital systems. Although the rate of hospital system acquisitions may be slowing, the local presence of hospital systems is growing. Locally concentrated systems have been formed by both for-profit and nonprofit hospitals. Researchers have tended to ignore acquisitions or have portrayed system formation as primarily an issue of hospital ownership conversion, thereby focusing on the expansion of national, for-profit systems. This has left a large gap in policymakers' understanding of how locally concentrated systems may affect patient care and competition.

On Nonexclusive Membership in Competing Joint Ventures

We evaluate the competitive and governance effects of duality. Duality refers to the joint membership (e.g., by banks) in competing associations or joint ventures (e.g., Visa and MasterCard). We first show that the not-for-profit nature of the associations along with the usage-based fees they charge yield productive efficiency. We then analyze the impact of (i) membership exclusivity, when the associations remain not-for-profit, and (ii) the conversion into for-profit systems. We illustrate the results in the case of a double-differentiation model that is of independent interest. Finally, we discuss extensions to (i) endogenous system differentiation, and (ii) agency considerations. Copyright 2003 by the RAND Corporation.

Acquisition of small rural hospitals by multihospital systems.

The occurrence of multihospital systems, two or more hospitals owned, leased, or managed by a separate organization, represents a note-worthy change in the way health care is organized today. The impact of this for small rural hospitals, however, has only been studied indirectly or anecdotally. This investigation, using data from national surveys, systematically documents and analyzes this trend and discusses its potential impact. By 1983 almost one quarter of all small rural hospitals were affiliated with multihospital systems. This growth occurred primarily over the last few years, and was accompanied by a rapid surge in the involvement of for-profit systems. This contrasts sharply with traditional rural hospital care which had been provided primarily by nonprofit or religious institutions. There also were differences in the form of affiliation the hospitals had with their parent organizations, with the most recent movement toward management contracts. Differential changes also occurred in the patterns of affiliation by geographic region.