Nonprofit Ownership Research Articles

Family Satisfaction With Nursing Home Care: Findings and Implications From Two State Comparison.

Family satisfaction, while recognized as important, is frequently missing from validated measures of long-term care quality. This is the first study to compare family satisfaction across two states using validated measures and to compare the organizational and structural factors associated with higher family satisfaction with nursing home care. Data sources are family satisfaction surveys from Minnesota (MN) and Ohio (OH), linked to facility characteristics from Certification and Survey Provider Enhanced Reports (CASPER) for both states (N = 378 facilities for MN; N = 926 facilities for OH). Activities and food were among lowest rated items in both states. Relationships with staff were the highest rated domain. Higher occupancy rates, smaller facility size, and non-profit ownership consistently predicted better satisfaction in both states. Our findings show consistent organizational factors associated with family satisfaction and provide further evidence to the validity of family satisfaction as a person-centered measure of quality. This lays the foundation for tool development on the national level.

Examination of the New Short-Stay Nursing Home Quality Measures: Rehospitalizations, Emergency Department Visits, and Successful Returns to the Community.

In 2016, the Centers for Medicare & Medicaid Services (CMS) introduced 3 new quality measures (QMs) to its report card, Nursing Home Compare (NHC). These measures—rehospitalizations, emergency department visits, and successful discharges to the community—focus on short-stay residents. We offer a first analysis of nursing homes’ performance in terms of these new measures. We examined their properties and distribution across nursing homes using descriptive statistics and regression models. We found that, similar to other QMs, performance varies across the country, and that there is very minimal correlation between these 3 new QMs as well as between these QMs and other NHC QMs. Regression models reveal that better performance on these QMs tends to be associated with fewer deficiencies, higher staffing and more skilled staffing, nonprofit ownership, and lower proportion of Medicaid residents. Other characteristics are associated with better performance for some but not all 3 QMs. We also found improvement in all 3 QMs in the second year of publication. This study contributes to the validity of these measures by demonstrating their relationship to these structural QMs. It also suggests that these QMs are important by demonstrating their large variation across the country, suggesting substantial room for improvement, and finding that nursing homes are already responding to the incentives created by publication of these QMs.

Do Safety Culture Scores in Nursing Homes Depend on Job Role and Ownership? Results from a National Survey.

To identify facility- and individual-level predictors of nursing home safety culture. Cross-sectional survey of individuals within facilities. Nursing homes participating in the national Agency for Healthcare Research and Quality Safety Program for Long-Term Care: Healthcare-Associated Infections/Catheter-Associated Urinary Tract Infections Project. Responding nursing home staff (N = 14,177) from 170 (81%) of 210 participating facilities. Staff responses to the Nursing Home Survey on Patient Safety Culture (NHSOPS), focused on five domains (teamwork, training and skills, communication openness, supervisor expectations, organizational learning) and individual respondent characteristics (occupation, tenure, hours worked), were merged with data on facility characteristics (from the Certification and Survey Provider Enhanced Reporting): ownership, chain membership, percentage residents on Medicare, bed size. Data were analyzed using multivariate hierarchical models. Nursing assistants rated all domains worse than administrators did (P < .001), with the largest differences for communication openness (24.3 points), teamwork (17.4 points), and supervisor expectations (16.1 points). Clinical staff rated all domains worse than administrators. Nonprofit ownership was associated with worse training and skills (by 6.0 points, P =.04) and communication openness (7.3 points, P =.004), and nonprofit and chain ownership were associated with worse supervisor expectations (5.2 points, P =.001 and 3.2 points, P =.03, respectively) and organizational learning (5.6 points, P =.009 and 4.2 points, P = .03). The percentage of variation in safety culture attributable to facility characteristics was less than 22%, with ownership having the strongest effect. Perceptions of safety culture vary widely among nursing home staff, with administrators consistently perceiving better safety culture than clinical staff who spend more time with residents. Reporting safety culture scores according to occupation may be more important than facility-level scores alone to describe and assess barriers, facilitators, and changes in safety culture.

Organizational and Community Factors Associated With Magnet Status of U.S. Hospitals

The Magnet Recognition Program for healthcare organizations promotes excellence in nursing services and professional practices. However, organizational and community characteristics that contribute to the adoption of Magnet status remain unexplained. Investigating organizational and community factors will help determine systematic structural and contextual dimensions of Magnet hospitals previously shown to be more cost-effective in comparison with non-Magnet hospitals. Using the baseline 2005 database of all Magnet hospitals in the United States, the authors selected a matched sample to determine key organizational and community characteristics associated with Magnet adoption while controlling for regional and local factors. Four tertiary databases were merged to identify measures of organizational and community characteristics of 132 Magnet hospitals and 264 non-Magnet pairs matched in closest proximity. The authors used bivariate tests and logistic regression to analyze the data. The findings show that Magnet adoption was positively associated with teaching affiliation, hospital size, nonprofit ownership, admission rates, and registered nurse (RN) staffing rates, but was negatively associated with licensed practical nurse (LPN) staffing rates. In the logit model, key organizational factors associated with the likelihood of Magnet adoption were larger hospitals, higher RN staffing rates, and lower LPN staffing rates. Key community factors were location in less densely populated counties and higher emergency department visit rates. The study findings reinforce previously established hypotheses that better RN staffing of Magnet hospitals is associated with higher cost-effectiveness. The study also adds key organizational and community factors that differentiate Magnet adoption. The Magnet concept as an innovative strategic choice assists healthcare leaders in better managing their resources to improve the cost-effectiveness of hospital care.

Foundation ownership, reputation, and labour

A number of firms in northern Europe and especially in Denmark are owned by private foundations similarly to what would have been the case if the Ford Foundation had owned a majority of the shares in Ford Motor Company. Foundation-owned companies appear to perform surprisingly well in terms of profitability and growth, despite lacking governance mechanisms such as profit incentives or takeover threats. Given their non-profit ownership, they might be expected to behave more responsibly towards stakeholders, such as employees or customers (Hansmann, 1980), but so far there has been little empirical evidence to support this hypothesis. This paper presents new research on the reputation and responsibility of foundation-owned companies. In a panel of large Danish companies 2001–11 we find that foundation-owned firms have better reputations and are regarded as more socially responsible in corporate image ratings. Secondary evidence on labour market behaviour is consistent with these findings. Using matched employer–employee data we show that foundation-owned companies are more stable employers, pay their employees better, and keep them for longer. Altogether, the evidence indicates that foundation-ownership is associated with more responsible business behaviour towards employees.

Incomplete Markets and Imperfect Institutions: Some Challenges Posed by Trust for Contemporary Health Care and Health Policy.

As contemporary health policy promotes evidence-based practices using targeted incentives, policy makers may lose track of vital aspects of care that are difficult to measure. For more than a half century, scholars have recognized that these latter aspects play a crucial role in high-quality care and equitable health system performance but depend on the potentially frail reed of providers' trustworthiness: that is, their commitment to facets and outcomes of care not easily assessed by external parties. More recently, early experience with pay for performance in health settings suggests that enhancing financial rewards for the measurable undermines providers' commitment to the unmeasurable, degrading the trustworthiness of their practices. Reformers have looked to revised professional norms or reorganized practice arrangements to bolster the intrinsic motivations required for trustworthiness. We suggest here that these responses are likely to prove inadequate. We propose that they be complemented by a renewed policy-making commitment to nonprofit ownership among health care providers, insurers, and integrated delivery systems. We identify some of the concerns raised in the past with ownership-based policies and propose a set of responses. If these are pursued in combination, they hold the promise of a sustainable ownership-based policy reform for the United States.

Which Hospital and Clinical Factors Drive 30- and 90-Day Readmission After TKA?

BackgroundThe purpose of this study was to analyze the hospital, clinical, and patient factors associated with inpatient readmission after total knee arthroplasty (TKA) in the Medicare population and to understand the primary reasons for readmission. MethodsThe Medicare 100% national hospital claims database was used to identify 952,593 older patients (65+) with a primary TKA in 3848 hospitals between 2010 and 2013. A multilevel logistic regression analysis with a clustered data structure was used to investigate the risk of all-cause 30- and 90-day readmission, incorporating hospital, clinical, and patient factors. ResultsAt 30 days, readmission ranged from 0% to 22% (median, 4.9%), whereas at 90 days, readmission ranged from 0% to 32% (median, 8.6%). Geographic census region, hospital procedure volume, rural hospital location, and nonprofit ownership were the only significant hospital factors among those we studied. Evaluation of clinical factors showed use of a perioperative transfusion was associated with 13% greater risk; patients discharged to home had 25% lower risk; and surgeon volume and length of stay were also significant. These effect sizes were at least comparable to patient factors, such as age, gender, comorbidities, and socioeconomic status. The top 5 most frequently reported primary reasons for 30- or 90-day readmission in TKA were surgery and medical related: wound infection, deep infection, atrial fibrillation, cellulitis and abscess of leg, or pulmonary embolism. ConclusionThe results of this study support further optimization of anti-infection measures, both intraoperative and postoperative, to reduce the broad variation in hospital readmissions.

Rural Implications of Expanded Birth Volume Threshold for Reporting Perinatal Care Measures

In 2016 the minimum annual birth volume threshold for required reporting of the Joint Commission Perinatal Care measures by accredited hospitals decreased from 1,100 to 300 births. Publicly available Joint Commission Quality Check data from April 2014 to March 2015 for three Perinatal Care measures were linked to Medicare Provider of Services and American Hospital Association Annual Survey data. For each measure, hospital-level reporting and performance among accredited hospitals providing obstetric care were compared using Fisher's exact tests. Sixty-seven percent of the 2,396 accredited hospitals with obstetric services reported at least one eligible patient for two of the four reported Perinatal Care measures: Elective delivery and exclusive breast milk feeding. Fewer hospitals (35.0%) had data on the antenatal steroids measure; many hospitals may not have any eligible patients for this measure. Hospitals with higher birth volume, those in urban counties, and those with private, nonprofit ownership or system affiliation were more likely to report the perinatal measures (p < 0.001). Across states, reporting rates varied considerably. By hospital volume, performance varied more on the antenatal steroids measure (78.0% to 91.5%) than on the breast milk feeding measure (48.4% to 49.5%) and the elective delivery measure (2.5% to 3.0%). Expansion of the minimum birth volume threshold nearly doubles the number of accredited hospitals required to report the Perinatal Care measures to The Joint Commission. However, 485 accredited hospitals with obstetric services that are either critical access hospitals or have fewer than 300 births annually are still exempt from reporting. Although many rural hospitals remain exempt from reporting requirements, the measures offer an opportunity for both rural and urban hospitals to assess and improve care.

Hospital, Patient, and Clinical Factors Influence 30- and 90-Day Readmission After Primary Total Hip Arthroplasty

BackgroundThe purpose of this study was to analyze the hospital, clinical, and patient factors associated with inpatient readmission after total hip arthroplasty (THA) in the Medicare population and to understand the primary reasons for readmission. MethodsThe Medicare 100% national hospital claims database was used to identify 442,333 older patients (65+) with a primary THA in 3730 hospitals between 2010 and 2013. A multilevel logistic regression analysis with a clustered data structure was used to investigate the risk of all-cause 30- and 90-day readmission, incorporating hospital, clinical, and patient factors. ResultsAt 30 days, 5.8% (median) of the patients were readmitted, whereas at 90 days, 10.5% (median) were readmitted. Geographic census region, hospital procedure volume, and nonprofit ownership were the only significant hospital factors among those we studied. Overall, clinical factors explained more of the variation in readmission rates than general hospital factors. Use of a perioperative transfusion was associated with 14% greater risk, patients discharged to home had 28% lower risk, and surgeon volume and length of stay were also significant risk factors. The top 5 most frequently reported primary reasons for 30-day readmission in THA were procedure related: dislocation (5.9%), deep infection (5.1%), wound infection (4.8%), periprosthetic fracture (4.4%), or hematoma (3.4%). ConclusionThese findings support further optimization of the delivery of care—both intraoperative and postoperative—to reduce the broad variation in hospital readmissions.

Are Hospice Admission Practices Associated With Hospice Enrollment for Older African Americans and Whites?

ContextHospices that enroll patients receiving expensive palliative therapies may serve more African Americans because of their greater preferences for aggressive end-of-life care. ObjectivesExamine the association between hospices' admission practices and enrollment of African Americans and whites. MethodsThis was a cross-sectional study of 61 North and South Carolina hospices. We developed a hospice admission practices scale; higher scores indicate less restrictive practices, that is, greater frequency with which hospices admitted those receiving chemotherapy, inotropes, and so forth. In separate multivariate analyses for each racial group, we examined the relationship between the proportion of decedents (age ≥ 65) served by a hospice in their service area (2008 Medicare Data) and admission practices while controlling for health care resources (e.g., hospital beds) and market concentration in the area, ownership, and budget. ResultsNonprofit hospices and those with larger budgets reported less restrictive admission practices. In bivariate analyses, hospices with less restrictive admission practices served a larger proportion of patients in both racial groups (P < 0.001). However, in the multivariate models, nonprofit ownership and larger budgets but not admission practices predicted the outcome. ConclusionHospices with larger budgets served a greater proportion of African Americans and whites in their service area. Although larger hospices reported less restrictive admission practices, they also may have provided other services that may be important to patients regardless of race, such as more in-home support or assistance with nonmedical expenses, and participated in more outreach activities increasing their visibility and referral base. Future research should explore factors that influence decisions about hospice enrollment among racially diverse older adults.

Wide Variation Found In Hospital Facility Costs For Maternity Stays Involving Low-Risk Childbirth

Childbirth is the leading cause of hospital admission in the United States, yet there has been little research on variation in hospital costs associated with childbirth. Using data from the 2011 Nationwide Inpatient Sample, we characterized the variation in estimated facility costs of hospitalizations for low-risk childbirth across US hospitals. We found that the average estimated facility cost per maternity stay ranged from $1,189 to $11,986 (median: $4,215), with a 2.2-fold difference between the 10th and 90th percentiles. Estimated facility costs were higher at hospitals with higher rates of cesarean delivery or serious maternal morbidity. Hospitals having government or nonprofit ownership; being a rural hospital; and having relatively low volumes of childbirths, low proportions of childbirths covered by Medicaid, and long stays also had significantly higher costs. The large variation in estimated facility cost for low-risk childbirths among hospitals suggests that hospital practices might be an important contributor to variation in cost and that there may be opportunities for cost reduction. The safe reduction of cesarean deliveries, increasing the coordination of care, and emphasizing value of care through new payment and delivery systems reforms may help reduce hospital costs and cost variation associated with childbirth in the United States.

Charity Care in Nonprofit Urban Hospitals: Analysis of the Role of Size and Ownership Type in Washington State for 2011

Nonprofit hospitals are expected to serve their communities as charitable organizations in exchange for the tax exemption benefits they receive. With the passage into law of the Affordable Care Act, additional guidelines were generated in 2010 to ensure nonprofit hospitals are compliant. Nonetheless, the debate continues on whether nonprofit hospitals provide adequate charity care to their patient population. In this study, charity care provided by 29 Washington State nonprofit urban hospitals was examined for 2011 using financial data from the Washington State Department of Health. Charity care levels were compared to both income tax savings and gross revenues to generate two financial ratios that were analyzed according to hospital bed size and nonprofit ownership type. For the first ratio, 97% of the hospitals (28 of 29) were providing charity care in greater amounts than the tax savings they accrued. The average ratio value using total charity care and total income tax savings of all the hospitals in the study was 6.10, and the median value was 3.46. The nonparametric Kruskal-Wallis test results by bed size and nonprofit ownership type indicate that ownership type has a significant effect on charity care to gross revenue ratios (p = .020). Our analysis indicates that church-owned hospitals had higher ratios of charity care to gross revenues than did the other two ownership types--government and voluntary--in this sample. Policy implications are offered and further studies are recommended to analyze appropriate levels of charity care in nonprofit hospitals given new requirements for maintaining a hospital's tax-exempt status.

Nursing Home Characteristics Associated with Resident Transfers to Emergency Departments

This study examined how nursing home facility ownership and organizational characteristics relate to emergency department (ED) transfer rates. The sample included a retrospective cohort of nursing home residents in the Vancouver Coastal Health region (n = 13,140). Rates of ED transfers were compared between nursing home ownership types. Administrative data were further linked to survey-derived data of facility organizational characteristics for exploratory analysis. Crude ED transfer rates (transfers/100 resident years) were 69, 70, and 51, respectively, in for-profit, non-profit, and publicly owned facilities. Controlling for sex and age, public ownership was associated with lower ED transfer rates compared to for-profit and non-profit ownership. Results showed that higher total direct-care nursing hours per resident day, and presence of allied health staff--disproportionately present in publicly owned facilities--were associated with lower transfer rates. A number of other facility organizational characteristics--unrelated to ownership--were also associated with transfer rates.

Effect of nursing home ownership on hospitalization of long-stay residents: an instrumental variables approach.

Hospitalizations among nursing home residents are frequent, expensive, and often associated with further deterioration of resident condition. The literature indicates that a substantial fraction of admissions is potentially preventable and that nonprofit nursing homes are less likely to hospitalize their residents. However, the correlation between ownership and hospitalization might reflect unobserved resident differences rather than a causal relationship. Using national minimum data set assessments linked with Medicare claims, we use a national cohort of long-stay residents who were newly admitted to nursing homes within an 18-month period spanning January 1, 2004 and June 30, 2005. After instrumenting for ownership status, we found that IV estimates of the effect of nonprofit ownership on hospitalization are at least as large as the non-instrumented effects, indicating that selection bias does not explain the observed relationship. We also found evidence suggesting the lower rate of hospitalizations among nonprofits was due to a different threshold for transfer.

Expansion in markets with decreasing demand-for-profits in the German hospital industry

Over the last 20 years, acute-care hospitals in most OECD countries have built up costly overcapacities. From the perspective of economic policy, it is desirable to know how hospitals of different ownership forms respond to changes in demand and are probably best suited to deal with existing overcapacities. This article examines ownership-specific differences in the responsiveness to changes in demand for hospital services in Germany between 1996 and 2006. With respect to the speed of adaptation to increasing demand, the study finds for-profit ownership to be superior to public and nonprofit ownership. However, contrary to other ownership types, for-profits also tend to expand in markets with decreasing demand - mainly through conversions of publicly owned hospitals. Thus, in short term, the privatization of the hospital sector may slow down the reduction of excess capacities and be therefore socially wasteful.

Expansion in Markets with Decreasing Demand - For-Profits in the German Hospital Industry

Over the last 20 years, acute care hospitals in most OECD have built up costly overcapacities. From the perspective of economic policy, it is desirable to know how hospitals of different ownership form respond to changes in demand and are probably best suited to deal with existing overcapacities. This paper examines ownership-specific differences in the responsiveness to changes in demand for hospital services in Germany between 1996 and 2006. With respect to the speed of adaptation to changes in demand, the study finds for-profit ownership to be superior to public and nonprofit ownership. Further, it is shown that declining demand can contribute to the expansion of for-profits through conversions by mainly publicly owned hospitals. Thus, the study finds evidence that to some extent the privatization of the hospital sector may be an adequate answer to reduce excess capacities.

Consumer Biases and Firm Ownership

Recent work has explored the implications of behavioral biases among consumers for firm behavior and has documented that profit-maximizing firms exploit consumer biases in the con- tracts they offer consumers. In this paper we show how ownership of the firm by its customers, as well as nonprofit ownership, can be used as commitment devices to avoid offering contracts that exploit consumer biases. In a model of a market in which for-profit investor-owned firms and mutual firms compete, sophisticated consumers who are biased but aware of their biases patronize mutual firms, while unbiased consumers and naive consumers who underestimate their biases patronize for- profit firms. Mutuals serving sophisticates offer high base prices but low prices, while for-profits offer low base prices and high penalty prices, resulting in transfers from naive biased consumers to unbiased consumers. We present evidence from the markets for credit cards, deposit accounts, and mutual funds that supports our theory. Comparing contract terms, we find mutuals do offer higher base prices but lower penalty prices than do for-profits. We also present evidence that customers sort into firms according to their perceptions of their own biases.

Hospital Collaboration with Public Safety Organizations on Bioterrorism Response

Objective. To identify hospital characteristics that predict collaboration with public safety organizations on bioterrorism response plans andmass casualty drills. Methods. The 2003 and2004 Bioterrorism andMass Casualty Supplements to the National Hospital Ambulatory Medical Care Survey examined collaboration with emergency medical services (EMS), hazardous materials teams (HAZMAT), fire departments, andlaw enforcement. The sample included 112 geographic primary sampling units and1,110 hospitals. Data were weighted by inverse selection probability, to yield nationally representative estimates. Characteristics included residency andmedical school affiliation, bed capacity, ownership, urbanicity andJoint Commission accreditation. The response rate was 84.6%. Chi-square analysis was performed with alpha set at p < 0.05. Logistic regression modeling yielded odds ratios with 95% confidence intervals. Results. During a bioterrorism incident, 68.9% of hospitals would contact EMS, 68.7% percent law enforcement, 61.6% fire departments, 58.1% HAZMAT, and42.8% all four. About 74.2% had staged mass casualty drills with EMS, 70.4% with fire departments, 67.4% with law enforcement, 43.3% with HAZMAT, and37.0% with all four. Predictors of drilling with some or all of these public safety organizations included larger bed capacity, nonprofit andproprietary ownership, andJCAHO accreditation. Medical school affiliation was a negative predictor of drilling with EMS.Conclusions. The majority of hospitals involve public safety organizations in their emergency plans or drills. Bed capacity was most predictive of drilling with these organizations. Medical school affiliation was the only characteristic negatively associated with drilling.

Ownership Issue Can Compromise Patient Care

ARNOLD S. RELMAN is professor emeritus of medicine and of social medicine at Harvard Medical School, Boston, and a former editor-in-chief of the New England Journal of Medicine. The views in this column are those of the writer. If you would like to express another viewpoint on this issue, please contact us at www.caringfortheages.com. About two-thirds of U.S. nursing homes are investor owned, mostly by large chains. Most nursing home income is derived from Medicaid and a smaller fraction from Medicare and out-of-pocket private payments. Payments are based on standard per diem charges, although they may vary according to the level of nursing care provided to residents, and, in the case of self-paying residents, by the amenities offered. With payment fixed, facilities generate net income only if they operate with economic efficiency. Everything else being equal, the less they spend on staffing and on service to residents, the more profit they make. A careful study published about 6 years ago in the American Journal of Public Health reported that serious deficiencies in care, found by government inspection, were 40% more frequent in private investor-owned nursing homes than in nonprofit private homes (Am. J. Pub. Health 2001;91:1452–55). Nurse staffing at the investor-owned facilities was 32% lower than in nonprofit facilities. Similar, but less rigorous, earlier studies had drawn the same general conclusions. A recent report in The New York Times has added to this evidence. The front-page story in the Sept. 23, 2007, issue reported that after investment companies acquired ownership of for-profit nursing home chains, deficiencies in care found by government regulators increased above the national average. The for-profit chains were selling out to the investment companies as a means of avoiding litigation over their many bad outcomes. Whenever corporate imperatives to generate profit for investors conflict with the requirements for optimum care, as they clearly do in investor-owned nursing homes, there is always the danger that management will cut corners to keep its costs down and maximize net income, thereby jeopardizing the safety of residents. Investor ownership, not just of nursing homes, but of almost any health care facility that is paid on a fixed per diem or per treatment basis, carries this same kind of risk. Their overhead expenses are almost always higher, and to meet investors' expectations, corporate managers must reduce the money spent on staff and services. They do not possess unique skills in cutting corners without compromising patient care, so fixed payment to investor-owned facilities is likely to affect the quality of care. The nursing home story is just one example of the mischief created by investor ownership of health care facilities. Health care should be regarded as a social service, not as a business or industry. Investors invaded the U.S. health care field a few decades ago, in search of profits—not to lower costs to payers, or to improve the quality or accessibility of services. There can be no comprehensive solution to the problems of health care in our country until we restore facilities to nonprofit ownership and replace current market forces with socially responsive regulation.

Serving Workers in the Human Services: The Roles of Organizational Ownership, Chain Affiliation, and Professional Leadership in Frontline Job Benefits

A growing body of research has sought to understand forces shaping firms' approaches to employee compensation and the impacts of job benefits on both organizational performance and worker well-being. One such line of work has documented advantages from employers adopting generous compensation practices, as evidenced by more successful worker recruitment and retention. Little of this work, however, has attended to benefits provided within nonprofit and public human service settings or to low-level workers. Drawing on a sample of Wisconsin nursing homes, this study addresses this gap by examining the roles of ownership, chain affiliation, and professional leadership in compensation provided to nursing assistants. Results indicate that public and nonprofit ownership and chain membership are positively related to benefit levels. Workers fare unexpectedly less well with professional directors in for-profit and public settings but better within professionally led nonprofits.