Assessing financial outcomes of not-for-profit community hospitals

Health care executives and health professionals often compare financial outcomes among not-for-profit community hospitals, such as operating margins and excess of revenue over expenses. Some performance measures used in these comparisons tend to be uniform yardsticks across community hospitals; other measures may vary significantly by legal, organizational, and reporting-practice differences among hospitals. A unique database of certified financial statements now permits an examination of these reporting-practice differences in the context of a three-year study of financial outcomes for 1,297 hospitals. Six panels are used in the study for partitioning hospitals in response to differences in reporting practices. Revenue over expenses expressed to net patient revenue and to total unrestricted assets are partially explained by 15 factors. The relative outcomes for these measures within a panel are combined with two common yardsticks of financial condition so the 1,297 hospitals can be classified into five status categories: (1) 121 hospitals in a crisis status, (2) 203 hospitals in a warning status, (3) 511 hospitals with average results, (4) 312 hospitals with excellent performance, and (5) 150 hospitals with outstanding performance.     

Characteristics of hospitals that outsource information system functions

Despite the increasing trend among hospitals to outsource information system functions, little is known about these decisions in the acute-care setting. This study examined the outsourcing behavior of hospitals in Florida to determine the characteristics of hospitals that are most likely to outsource IS functions. In addition, the results provide an overview of which IS functions are most commonly outsourced in hospitals. Overall, survey responses from 98 hospitals indicate that the outsourcing of IS functions is more common in small hospitals and those in rural areas. Another important predictor of IS outsourcing behavior was the degree to which an organization placed a strategic importance on IS in its operations. Outsourcing behavior did not seem to be systematically related to the CIO reporting structure. However, having a physician in a senior level IT position did seem to correlate. Lastly, the data indicate that a hospital's profit status is not generally related to IS outsourcing.     

Hospital financial performance: does IT governance make a difference?

This study examined whether information technology (IT) governance, a term describing the decision authority and reporting structures of the chief information officer (CIO), is related to the financial performance of hospitals. The study was conducted using a combination of primary survey data regarding health care IT adoption and reporting structures of Florida acute care hospitals, with secondary data on hospital financial performance. Multiple regression models were used to evaluate the relationship of the 3 most commonly identified reporting structures. Outcome variables included measures of operating revenue and operating expense. All models controlled for overall IT adoption, ownership, membership in a hospital system, case mix, and hospital bed size. The results suggest that IT governance matters when it comes to hospital financial performance. Reporting to the chief financial officer brings positive outcomes; reporting to the chief executive officer has a mixed financial result; and reporting to the chief operating officer was not associated with discernible financial impact.     

Global budgets in Maryland: early evidence on revenues,expenses, and margins in regulated and unregulated services

Maryland implemented one of the most aggressive payment innovations the nation has seen in several decades when it introduced global budgets in all its acute care hospitals in 2014. Prior to this, a pilot program, total patient revenue (TPR), was established for 8 rural hospitals in 2010. Using financial hospital report data from the Health Services Cost Review Commission from 2007 to 2013, we examined the hospitals’ financial results including revenue, costs, and profit/loss margins to explore the impact of the adoption of the TPR pilot global budget program relative to the remaining hospitals in the state. We analyze financial results for both regulated (included in the global budget and subject to rate-setting) and unregulated services in order to capture a holistic image of the hospitals’ actual revenue, cost and margin structures. Common size and difference-in-differences analyses of the data suggest that regulated profit ratios for treatment hospitals increased (from 5% in 2007 to 8% in 2013) and regulated expense-to-gross patient revenue ratios decreased (75% in 2007 and 68% in 2013) relative to the controls. Simultaneously, the profit margins for treatment hospitals’ unregulated services decreased (??12% in 2007 and ??17% in 2013), which reduced the overall margin significantly. This analysis therefore indicates cost shifting and less profit gain from the program than identified by solely focusing on the regulated margins.     

吉林省县级公立医院改革后“看病难、看病贵”现状研究

目的:通过吉林省县级公立医院财务数据分析和就诊患者问卷调查,了解县级公立医院全面改革后"看病难、看病贵"现状,为新医改政策制定提供依据。方法:根据医院HIS系统收集吉林省县级公立医院卫生费用数据,同时,对789名到县级公立医院就医的患者进行问卷调查。结果:2014—2016年,医院门急诊次均费用、次均住院费用、医院总收入、医院医疗收入、医院财政补贴收入、医院医保收入均逐年增加;药品收入占医院总收入比例、药品收入占医院医疗收入比例、患者个人自付费用占医院总收入比例、患者个人自付费用占医院医疗收入比例均逐年降低;8.4%的被调查患者认为"看病难",26.2%被调查者认为"看病贵",医保参保率达到96.7%,14.7%的被调查患者对医保报销比例表示不满意。结论:县级公立医院改革后,收入发生了结构性改变,患者"看病难"问题明显改善,"看病贵"问题仍有待进一步解决。     

Do patient perceptions of quality relate to hospital financial performance?

Analysis confirms that patient perceptions of quality are associated with hospital financial performance. Multivariate analysis involving more than 15,000 patients discharged from 51 medical/surgical hospitals shows that discrete dimensions of hospital quality (i.e., medical and billing systems and discharge processes) explain approximately 17%-27% of the variation in financial measures such as hospital earnings, net revenue, and return on assets. The findings suggest that measurable improvements in patients' judgments of hospital quality might translate into better financial performance. The implications of these results and the limitations of the study are discussed.     

Hospital information technology and positive financial performance: a different approach to finding an ROI

This empirical study examined the relationship between information technology (IT) utilization and hospital financial performance. Using primary and secondary data, we specified and tested a series of regression models that examined this relationship in Florida hospitals. In addition, we employed performance group analysis for a select group of operational performance indicators. Findings suggested a significant and positive relationship between increased levels of IT use and various measures of financial performance, even after controlling for case-mix acuity and bed size. Regardless of the analysis or method employed, the results indicated that IT adoption is consistently related to improved financial outcomes both overall and operationally. This relationship was present when examining IT collectively and for clinical IT, administrative IT, and strategic IT as individual measures. Lastly, although higher IT use was associated with a higher level of revenues, income, or cash flow, higher use was also associated with ratios based on higher expenses. This probably reflects the relatively high acquisition costs associated with obtaining and maintaining sophisticated IT systems. Given that a true return on investment is so difficult to obtain for many individual hospitalwide IT systems, our data can serve as a proxy for hospital leaders and policymakers who want to understand the potential financial effects of investing in IT in the acute care setting.     

To outsource or not to outsource

Outsourcing work can be a positive intervention if the environment and strategies are properly coordinated, but there is no guarantee of success. Today, more than ever before, hospitals are suffering from two pressures: economic constraints and the migration of managerial talent out of the field to other sectors of the economy. With these two pressures, hospitals are searching for ways to reduce costs and find skilled personnel. A common strategy is to seek support from the open market and outsource. This article looks at tools for making the outsourcing decision, such as risk and force field analysis.     

Hospital adoption of information technologies and improved patient safety: a study of 98 hospitals in Florida

Most of the studies linking the use of information technology (IT) to improved patient safety have been conducted in academic medical centers or have focused on a single institution or IT application. Our study explored the relationship between overall IT adoption and patient safety performance across hospitals in Florida. Primary data on hospital IT adoption were combined with secondary hospital discharge data. Regression analyses were used to examine the relationship between measures of IT adoption and the Patient Safety Indicators (PSIs) of the Agency for Healthcare Research and Quality. We found that eight PSIs were related to at least one measure of IT adoption. Compared with administrative IT adoption, clinical IT adoption was related to more patient safety outcome measures. Hospitals with the most sophisticated and mature IT infrastructures performed significantly better on the largest number of PSIs. Adoption of IT is associated with desirable performance on many important measures of hospital patient safety. Hospital leaders and other decision makers who are examining IT systems should consider the impact of IT on patient safety.     

浙江省县级公立医院改革试点医院收支状况分析

目的 分析浙江省县级公立医院综合改革对县级公立医院收支状况的影响。方法 收集浙江省2011年12月启动改革的5个县（市）22家医院2011-2013年上半年的收入和支出数据,对定量资料采用描述性统计分析。结果 县级公立医院综合改革后,医院收入结构变化明显,一方面政府财政补助额度逐年提高,财政补助占医院总收入的比例上升;另一方面,药品收入占医疗收入的比例逐年下降,药品收支结余对医院的补偿能力逐步减弱。结论 浙江省县级公立医院在改革实施后,依托合理的医疗服务调价手段和政府财政的有力支持,县级公立医院改革平稳推进。     

县级公立医院医药分开改革对医院收入和医疗服务的影响——基于广西的实证分析

目的:评价广西县级公立医院医药分开改革对医院收入和医疗服务的影响。方法:采用前后对照设计,2009—2012年为干预前,2013年为干预期,试点县级公立医院为干预组,非试点县级公立医院为对照组;数据来源于2009—2013年医院统计报表和新农合报表、2010—2014年广西统计年鉴;采用基于回归的倍差法进行分析。结果:医药分开改革包括取消药品加成、提高诊查费和护理费项目价格、降低大型设备检查项目价格和增加财政补助;在医院收入方面,相对于非试点医院,试点医院药品收入减少332.6万元、医疗收入增加1 075万元,财政补助没有显著变化;在医疗费用方面,相对于非试点医院,试点医院次均门诊药品费用减少3.51元、次均门诊诊查费用增加2.23元、次均住院药品费用减少133.50元、次均住院诊查费用增加62.01元、次均住院护理费用增加69.72元,门诊和住院人次、平均住院日、次均门诊和住院费用均无显著变化。结论:县级公立医院住院医疗服务价格调整弥补了取消药品加成带来的损失,门诊需通过政策外项目费用调整来弥补损失。医药分开改革没有减少试点医院业务收入,但对医院和医生的激励作用有限。     

Networks and the Fiscal Performance of Rural Hospitals in Oklahoma: Are They Associated?

This paper uses regression analysis to explore the relation of network membership to the financial performance of rural hospitals in Oklahoma during fiscal year 1995. After adjusting for the scope of service, as measured by the number of facilities or services offered by the hospital, indicators of fiscal status are (1) the cash receipts derived from net patient revenue; (2) the cash disbursements related to operating costs, net of interest and depreciation expense, labor costs and nonlabor costs; and (3) net cash flow, defined as the difference between cash receipts and disbursements. Controlling for the effects of the hospital's structural attributes, operating characteristics and market conditions, the results indicate that members of a network reported lower net operating costs, labor costs and nonlabor expenses per service than nonmembers. Hence, the analysis seems to suggest that the membership of rural hospitals in a network is associated with lower cash disbursements and an improved net cash flow, outcomes that may preserve their fiscal viability and the access of the population at risk to service.     

Profitability analysis in the hospital industry.

Measures of marginal profit are derived for the two payment classes--cost payers and charge payers--that the hospital industry must consider in profitability analysis, i.e., prediction of the excess of revenue over expenses. Two indexes of profitability, use when payment mix is constant and when it is nonconstant, respectively, are derived from the two marginal profit measures, and one of them is shown to be a modification of the contribution margin, the conventional measure of profitability used in general industry. All three measures--the contribution margin and the two new indexes of profitability--are used to estimate changes in net income resulting from changes in patient volume with and without accompanying changes in payment mix. The conventional measure yields large overestimates of expected excess revenue.     

Hospital quality of care: does information technology matter? The relationship between information technology adoption and quality of care

BACKGROUND: Hospitals have been slow to adopt information technology (IT) largely because of a lack of generalizable evidence of the value associated with such adoption. PURPOSE: To explore the relationship between IT adoption and quality of care in acute-care hospitals. METHODS: Primary data on hospital IT adoption were combined with secondary hospital discharge data. Regression analyses were used to examine the relationship between various measures of IT adoption and several quality indicators after controlling for confounders. Adoption of IT was measured using a previously validated method that considers clinical, administrative, and strategic IT capabilities of acute-care hospitals. Quality measures included the Inpatient Quality Indicators developed by the Agency for Healthcare Research and Quality. RESULTS: Data from 98 hospitals were available for analyses. Hospitals adopted an average of 11.3 (45.2%) clinical IT applications, 15.7 (74.8%) administrative IT applications, and 5 (50%) strategic IT applications. In multivariate regression analyses, hospitals that adopted a greater number of IT applications were significantly more likely to have desirable quality outcomes on seven Inpatient Quality Indicator measures, including risk-adjusted mortality from percutaneous transluminal coronary angioplasty, gastrointestinal hemorrhage, and acute myocardial infarction. An increase in clinical IT applications was also inversely correlated with utilization of incidental appendectomy, and an increase in the adoption of strategic IT applications was inversely correlated with risk-adjusted mortality from craniotomy and laparoscopic cholecystectomy. PRACTICE IMPLICATIONS: Hospital adoption of IT is associated with desirable quality outcomes across hospitals in Florida. These findings will assist hospital leaders interested in understanding better the effect of costly IT adoption on quality of care in their institutions.     

Taxation of nonprofit hospitals: a cost impact model

At a time when taxing authorities at all levels of government are reexamining present exemptions, nonprofit charitable hospitals may become concerned about potential new tax liabilities. The Tax Impact Model described here can predict the dollar amount of new taxes, the probable amount of shortfall in major payers' reimbursement for these expenses, and the resulting net financial impact. This model incorporates a set of issues that should be considered and factors for which data or assumptions are needed. It can be applied to hospitals singly or in groups. Here, the model's application to a single hospital shows that payer mix and pretax financial strength are important determinants of the impact of taxation. These findings also suggest that hospitals with a large disproportion of Medicare and Medicaid patients, and those with small revenue margins, are least able to absorb new tax expenses.     

What Hospital Implementation Strategies Are Associated with Successful Performance Under Maryland’s All-Payer Model?

In January 2014, Maryland shifted its all-payer hospital rate setting system from one that paid hospitals based on charges per case to a fixed global budget payment model. Under Maryland’s All-Payer Model (MDAPM), hospitals had considerable flexibility to implement strategies to meet their global budget and other model goals, including improving quality, safety, and patient satisfaction. We conducted a comparative case study to identify the implementation strategies used in hospitals with successful outcomes under MDAPM. We conducted a mixed-method analysis that examined the association between changes in hospital performance and the use of different implementation strategies. We used data from a survey fielded among all Maryland acute care hospitals from October to December 2018 that examined whether hospitals implemented 28 strategies, either before or during MDAPM. We complemented survey data with qualitative data collected from site visits to all hospitals and focus group discussions with hospital-based nurses and physicians conducted from April 2015 to February 2019. We calculated two hospital-level measures to assess performance—operating margin (financial performance) and Medicare 30-day unplanned readmission rate (patient care performance). We used hospital financial reports to calculate change in operating margin from a two-year baseline period (FY2012-FY2013) to a five-year implementation timeframe (FY2014-FY2018). For readmissions, we calculated the change from a three-year baseline period (January 2011-December 2013) to a 4.5-year implementation timeframe (January 2014-June 2018). We established four performance categories for each outcome based on a hospital’s pre-post change: decline and low, medium, or high improvement. For financial performance, improvement was an increase in operating margin. For patient care, performance improvement was a decrease in readmissions. Cut points for low, medium, and high improvement were based on the distribution of each outcome. 46 Maryland acute care hospitals. Two strategies—employing physician staff and providing patients with clinically specific education—were associated with improvements in both performance outcomes. Eight strategies were associated with improved patient care performance, such as utilizing customized data analytics, engaging physicians in implementing MDAPM-related strategies, investing in interventions that address social determinants of health, and referring patients to alternative care settings. Three strategies were associated with improved financial performance, including using Maryland’s health information exchange and participating in a program to improve alignment with physicians. Six strategies were not associated with either performance measure. Eight strategies were employed by nearly all Maryland hospitals and, therefore, could not be associated with hospital performance. Almost half of the strategies examined were associated with at least one of the dimensions of successful performance examined. The comparative case study approach does not provide a causal perspective on hospital performance. Thus, we cannot determine whether adopting these strategies improved hospital performance or whether improvements in performance facilitated hospitals’ ability or desire to implement these strategies. Hospitals seeking to improve their performance may want to emphasize the two implementation strategies that were associated with greater success in both patient care and financial performance. Hospitals operating under a global budget model may consider adopting the eight strategies implemented by nearly all Maryland hospitals as implementation building blocks. Centers for Medicare and Medicaid Services.     

HMO penetration: has it hurt public hospitals?

The purpose of this study is to determine the extent to which health maintenance organization (HMO) penetration within the public hospitals' market area affects the financial performance and viability of these institutions, relative to private hospitals. Hospital- and market-specific measures are examined in a fully interacted model of over 2,300 hospitals in 321 metropolitan statistical areas (MSAs) in 1995. Although hospitals located in markets with higher HMO penetration have lower financial performance as reflected in revenues, expenses and operating margin, public hospitals are not more disadvantaged than other hospitals by managed care.     

Hospital financial condition and the quality of patient care

Concerns about deficiencies in the quality of care delivered in US hospitals grew during a time period when an increasing number of hospitals were experiencing financial problems. Our study examines a six-year longitudinal database of general acute care hospitals in 11 states to assess the relationship between hospital financial condition and quality of care. We evaluate two measures of financial performance: operating margin and a broader profitability measure that encompasses both operating and non-operating sources of income. Our model specification allows for gradual adjustments in quality-enhancing activities and recognizes that current realizations of patient quality may affect future financial performance. Empirical results suggest that there is a relationship between financial performance and quality of care, but not as strong as suggested in earlier research. Overall, our results suggest that deep financial problems that go beyond the patient care side of business may be important to prompting quality problems.     

南京市属公立医院医药价格综合改革补偿效果评价

目的:分析南京市城市公立医院医药价格综合改革后各医院药品收支、医疗服务收入变化,评价补偿效果,探索差异化补偿方案,为建立动态调整的补偿机制提供依据。方法:选择市属参改医院共10家,收集改革前48个月(2011.11—2015.10)及改革后12个月(2015.11—2016.10)财务收支数据,采用简单线性间断时间序列模型对药品收支差率、取消药品加成损失、医疗服务收入增长率、财政补偿率、医疗服务收入补偿率、综合补偿率进行分析。结果:改革后平均药品收支差率净下降14.24个百分点,医疗服务收入净增长24.29%;药占比平均从42.7%下降到36.9%,医疗服务占比从26.1%上升到30.3%。补偿上,净财政补偿率平均为20.43%、净服务补偿率平均为87.34%,达到政策目标,但净服务补偿率从-21.92%到712.52%不等、净综合补偿率从28.87%到712.52%不等,差异较大。其中,服务补偿率与改革前医疗服务收入占比显著正相关。结论:南京价改在取消药品加成和"80%服务+20%财政"补偿效果上政策目标基本实现,但各医院之间差异较大,服务依赖型医院补偿率超过400%,药品依赖型不到30%,而综合性医院因医疗收入结构和经营效率不同,从50%到100%不等。建议:进一步落实调价范围和调价力度,按年建立动态且差异化的补偿机制。     

贵州省县级民营医院经济运行现状分析

目的分析贵州省县级民营医院经济运行的情况,了解民营医院在贵州省的发展现状。方法通过简单随机抽样抽取贵州省具有医保定点资格的县级民营医院20个,同时将样本医院所在县的27个县级公立医院纳入对照研究,收集样本医院2014年的财务报表,通过比较分析法,分析贵州省县级民营医院在设施设备、财务收支、融资借贷、药占比、人员经费占比等方面的现状。结果民营医院拥有万元以上设备总价值为7 116万元,万元以上设备561台;民营医院收入结余2 368万元,占总收入的10.18%,收支构成经卡方检验,差异有统计学意义（P<0.01）;民营医院药占比43.52%;民营医院人员经费占业务支出比31.38%;有两家民营医院向金融机构借贷了200万元,民营医院病人累积欠费102万元,2014年欠费60万元,占2014年总收入的0.26%。结论民营医院经济运行尚可,在与公立医院的竞争中面临较大的压力,但在年度结余占比上仍然高于公立医院,财务控制较好。但是由于缺少政策支持,融资面临一定的困难,发展面临巨大的挑战。