Charitable care and the nonprofit paradigm

Nonprofit hospitals have begun to focus once again on serving the health needs of their communities. Governmental needs for additional revenue and for-profit hospitals' contention that tax exemptions give nonprofit hospitals an unfair competitive advantage have resulted in changes in laws and regulations and have caused a change in the role of nonprofit hospitals. As local governments become more responsive to the health needs of their communities, they are requiring nonprofit hospitals to become more responsive as well. Laws, regulations, and court decisions have begun to require nonprofit hospitals to provide charity care and services at levels equal to the amount of their exempt taxes. In response, nonprofit hospitals are developing community benefit programs and public health services.     

Health care for the poor: some policy alternatives

Changes in the financing and organization of medical care are most likely to affect adversely the poor who have significant needs for care, but face increasingly stringent eligibility criteria in Medicaid and other public programs. Americans estimated to have neither private nor public health insurance coverage number 33 million persons, and with increased cost pressures, voluntary and proprietary hospitals are less willing to treat such patients. One quarter of hospitals provide 60 percent of all care to the poor, and many of these nonprofit and public hospitals face economic difficulties and an erosion of public commitment. Alternative solutions include publicly subsidized premiums for the poor and near poor and assistance to financially stressed hospitals caring for large numbers of such persons. Mechanisms include all-payer systems, taxes on net hospital revenue or insurance premiums, or contributions from general tax revenues. Financing poses special problems, but it is also necessary to address the special needs of children and the elderly, the appropriate balance between technical and cognitive services, and new ways to maintain health and promote effective functioning. These issues pose challenges and opportunities for family practice.     

Private tax-cut plans. Columbia, Tenet push for lower property assessments, despite community-benefit argument

The nation's two largest for-profit hospital chains have adopted another cost-cutting strategy: They've hired a small army of consultants and lawyers to persuade local tax assessors that many of their hospitals are overvalued, so they should pay less in real estate taxes. But the strategy carries some risk for the for-profits, which usually cite tax payments as one of their "community benefits."     

Guest Commentary: Fat and other taxes,lessons for the implementation of preventive policies

Fat, sugar or sweetened beverage taxes are part of an overall public health nutrition approach to healthy eating. They are not approaches that on their own are likely to bring about change. Policy evidence from existing food tax implementation suggest that taxes need to be paralleled by subsidies and other interventions to encourage healthy eating. Such dual methods help not only contribute to nutrition outcomes but also ensure political support for food taxes. Politicians and policy makers are suspicious of taxes, using subsidies and revenue monies from taxes to support healthy eating is more likely to encourage both political and public support. Building support for policies is never just a matter of academic evidence. Public health advocates need to show more ambition by developing skills in implementing pricing policies to support healthy eating. Key opponents to taxes are the food industry who use a range of arguments to prevent taxation being implemented. Public health advocates are weak in tackling the issues of corporate power and providing evidence to maintain policy and political support.The public health movement needs to continue to develop the political will among politicians and the public for taxes on food. A new way of looking at policy formation is required and this includes addressing the power of corporate interests and the role of professionals in shaping or combating these influences.     

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.     

Implications of the Supplemental Nutrition Assistance Program Tax Exemption on Sugar-Sweetened Beverage Taxes

US state and local governments are debating sugar-sweetened beverage excise taxes to support public health. A related issue is whether such taxes would apply to beverage purchases made by Supplemental Nutrition Assistance Program (SNAP) participants. Federal law proscribes states from collecting excise taxes on SNAP purchases, but the law is confined to taxes at the point of sale. I provide legal analysis and recommendations for policymakers to enact taxes that are not subject to the SNAP tax exemption to potentially deter consumption by all consumers.Many US state and local governments are engaged in activity to pass sugar-sweetened beverage taxes to support public health and raise revenue. Berkeley, California, passed the nation’s first sugar-sweetened beverage tax for this purpose in November 2014. Legislative bills and literature on the subject focus on excise taxes because they have administrative advantages, they result in an increase in the price of the product, and the revenue can be earmarked for other public health programs. Excise taxes are levied on the businesses engaged in the manufacture, distribution, use, or sale of products; these entities are expected to recover the cost by increasing the base price of the product, unlike sales taxes, which are administered at the point of purchase. See

News Coverage of Sugar-Sweetened Beverage Taxes: Pro- and Antitax Arguments in Public Discourse

Objectives. We examined news coverage of public debates about large taxes on sugar-sweetened beverages (SSBs) to illuminate how the news media frames the debate and to inform future efforts to promote obesity-related public policy.Methods. We conducted a quantitative content analysis in which we assessed how frequently 30 arguments supporting or opposing SSB taxes appeared in national news media and in news outlets serving jurisdictions where SSB taxes were proposed between January 2009 and June 2011.Results. News coverage included more discrete protax than antitax arguments on average. Supportive arguments about the health consequences and financial benefits of SSB taxes appeared most often. The most frequent opposing arguments focused on how SSB taxes would hurt the economy and how they constituted inappropriate governmental intrusion.Conclusions. News outlets that covered the debate on SSB taxes in their jurisdictions framed the issue in largely favorable ways. However, because these proposals have not gained passage, it is critical for SSB tax advocates to reach audiences not yet persuaded about the merits of this obesity prevention policy.A growing body of evidence indicates that consuming sugar-sweetened beverages (SSBs), which include nondiet sodas, energy drinks, and fruit drinks, is associated with higher obesity rates.1–3 Some researchers argue that SSBs are the single largest driver of increasing obesity rates in the United States.4 This evidence has led public health advocates and researchers to search for effective solutions to reduce SSB consumption.Recent research suggests that large (e.g., penny per ounce) taxes on SSBs would reduce consumption and obesity rates.5,6 Although most US states already collect some form of tax on SSBs, these taxes are small relative to the price of these products.7 Many US states and cities (e.g., California, Mississippi, Philadelphia, PA) have considered larger taxes.8 To date, efforts to collect larger SSB taxes have been unsuccessful. Public opinion polls provide mixed evidence about public support for these taxes.9–11 One recent, national survey found substantially higher public agreement with anti-SSB tax than pro-SSB tax arguments.12Understanding how the news media has framed SSB tax debates can shed light on how the political process has played out in various communities. Framing involves emphasizing some aspects of an issue to the exclusion of others.13 Advocates and opponents of specific policies seek to shape policy debates by framing the policy issue in ways that they see as favorable to their positions and by advocating media coverage that employs these frames.14–16 The news media, in turn, help to shape the policy agenda by selecting issues to cover and framing them in ways that invite particular policy interpretations.13,17,18 For example, an interest group might frame a policy issue by highlighting its economic consequences, whereas another group might make an explicit link between the issue and broader values, such as social justice. The news media choose to highlight these or other frames in their coverage, which in turn can influence how the public thinks about these issues.19 A systematic analysis of arguments used in support of and arguments used in opposition to a policy issue, as well as the types of advocates and opponents who participated in the debate, thus provides valuable political context about the issue in question.Such contextual information is particularly important for policies on SSB taxes, characterized by politically polarized views among the public.10,20,21 SSB tax advocates are more likely to succeed at attracting large coalitions of support if they employ frames that resonate across the political spectrum.22 Identifying message frames that SSB tax proponents (typically leaning liberal) and opponents (typically leaning conservative) use and the news media cover can illuminate how various interest groups cast the terms of the debate to resonate with their constituents. Collecting data about the information environment can be helpful for designing future campaigns to increase support for SSB taxes and other obesity-related policies.23     

Hospital Accounting and Statistical Problems

The recent overhauling of the Federal tax code has made the front pages. The following condensation of the highlights of the code is based on material supplied by the American Institute of Accountants, the national professional society of certified public accountants

It should be of specific interest to all proprietary hospitals, and may contain features of interest to voluntary hospitals. Though in general the new tax law is more liberal toward business than the old one, some loopholes have been plugged and some provisions bear down a little harder

The sweeping new tax code is estimated to have cut $1,363,000,000 from, business and personal taxes tnis fiscal year. The question is, “Will your hospital get its share of tax relief?”     

美国非营利医院与营利医院的区别和竞争

美国非营利性医院约占85%,营利性医院约占15%,两者主要的区别表现在:非营利性医院提供很多社区服务、健康教育等社会福利,它的收支节余不能用于分红。而营利性医院的一个主要目的就是为业主或股东赚取利润。另外,非营利性医院享受政府的免税政策,1996年,全美该项免税额为85亿美元。无论是营利性医院或者非营利性医院都必须有盈利,否则不可能生存下去。     

Euthanasia and end-of-life practices in France and Germany. A comparative study

The objective of this paper is to understand from a sociological perspective how the moral question of euthanasia, framed as the “right to die”, emerges and is dealt with in society. It takes France and Germany as case studies, two countries in which euthanasia is prohibited and which have similar legislation on the issue. I presuppose that, and explore how, each society has its own specificities in terms of practical, social and political norms that affect the ways in which they deal with these issues. The paper thus seeks to understand how requests for the “right to die” emerge in each society, through both the debate (analysis of daily newspapers, medical and philosophical literature, legal texts) and the practices (ethnographic work in three French and two German hospitals) that elucidate the phenomenon. It does so, however, without attempting to solve the moral question of euthanasia. In spite of the differences observed between these two countries, the central issue at stake in their respective debates is the question of the individual’s autonomy to choose the conditions in which he or she wishes to die; these conditions depend, amongst others, on the doctor-patient relationship, the organisation of end-of-life care in hospital settings, and more generally, on the way autonomy is defined and handled in the public debate.     

Not-for-profits: business basics for survival

Many not-for-profit hospitals are struggling to keep their doors open. Although executives often contend that they are not playing on a level field, the fundamental cause is the hospital's failure to earn an excess of revenue over expenses. The tax exemption enjoyed by a not for profit can be a tremendous advantage. Some may argue that uncompensated care negates that benefit, but uncompensated care is a problem for the industry, not just not-for-profit institutions. The real issue at stake is the not-for-profit mentality--a belief that a tax-exempt business is not supposed to make money. On the contrary, our goal is to provide much-needed services to the community, and to do that well, we must make money. When solid business practices are followed, a hospital will be able to provide the basic healthcare services needed with positive financial results.     

Employers look to hospitals to help control costs

The high cost of health insurance for employees is forcing employers to take a second look at ways to control their rising costs, and they are looking for help from hospitals, according to a national study conducted by National Research Corp. In addition, four out of 10 employers surveyed said they believe more taxes should be shifted to hospitals and healthcare services.     

THE POVERTY EFFECTS OF A ‘FAT‐TAX’ IN IRELAND

To combat growing levels of obesity, health‐related taxes have been suggested with taxes on foods high in fat or sugar. Such taxes have been criticised on the basis of their regressivity and potentially adverse impact upon poverty. This paper analyses the effect of such taxes on a range of poverty measures and also examines the effect of a revenue‐neutral tax subsidy mixed with a tax on unhealthy food combined with a subsidy on more healthy food. Using Irish expenditure data, the results indicate that taxes on high fat/sugar goods on their own will be regressive but that a tax‐subsidy combination can be broadly neutral with respect to poverty. Copyright © 2013 John Wiley & Sons, Ltd.     

Decision analysis and polio immunization policy.

Dr. Salk's comments on our paper fall into four major categories: our use of the techniques of decision analysis, the assumptions we used, the fact that we did not include individual and social values in the model, and the way in which vaccine policies are developed in the United States. We believe that the methods were used correctly, that the assumptions we used are defensible, and that our conclusions were both appropriate and appropriately worded. We explicitly did not include individual and social values since we were addressing the scientific and epidemiologic issues rather than ethical and moral issues. Vaccine policy development in the United States is carried out in public forums with opportunity for presentation of all sides of an issue.     

The economics of for-profit and not-for-profit hospitals

This paper examines the economics of for-profit and not-for-profit hospitals through the prism of capital acquisitions. The exercise suggests that of two hospitals that are equally efficient in producing health care, the for-profit hospital would have to charge higher prices than the not-for-profit hospital would, to break even on capital acquisitions. The reasons for this divergence are (1) the typically higher cost of equity capital that for-profit hospitals face; and (2) the income taxes they must pay. The paper recommends holding tax-exempt hospitals more formally accountable for the social obligation they shoulder, in return for their tax preference.     

Health care reform: public views of problems and solutions

Public opinion surveys have found growing discontent with the health care system. In response, major reform legislation has been introduced in Washington and in many statehouses as well. Nonetheless, very few, if any, state-level public opinion surveys examining health care have been conducted in the South. During November of 1991, a statewide survey of 1,250 Alabamians was conducted to collect information on a wide range of health care issues. The survey is perhaps the largest and most complete survey on health care issues ever conducted in a southern state. Major findings of the survey are as follows: (1) Two-thirds of Alabamians believe the health care system needs fundamental change or needs to be completely rebuilt; however, there is little consensus on the shape of this new health care system. (2) Over 50 percent of Alabamians believe that rising health care costs are the most important issue facing the country. Yet, only about one-third support managed-care mechanisms as a means of controlling personal health care costs. (3) Four of ten Alabamians believe access to care is a critical health care issue. Nonetheless, only 16 percent are willing to pay more than $100 in additional annual taxes to guarantee health care for everyone. This survey yields a set of conflicting conclusions. Policy makers and elected officials should be aware of these issues as they attempt to forge health care reform legislation.     

Sugary Beverage Tax Policy: Lessons Learned From Tobacco

Excise taxes on sugary beverages have been proposed as a method to replicate the public health success of tobacco control and to generate revenue. As policymakers increase efforts to pass sugary beverage taxes, they can anticipate that manufacturers will emulate the strategies employed by tobacco companies in their attempts to counteract the impact of such taxes. Policymakers should therefore consider 2 complementary laws—minimum price laws and prohibitions on coupons and discounting—to accomplish the intended price increase.EXCESSIVE SUGARY BEVERAGE consumption is associated with metabolic changes and increased risk for diabetes, coronary heart disease, and obesity.1 Excise taxes on sugary beverages have been proposed as a method to replicate the public health successes of tobacco control and to generate revenue that could be used for other public health strategies and help finance government activity.1 The reduction of smoking incidence and prevalence in the United States is partially attributed to the implementation of several successful policy strategies, one of which is increased excise taxes.2The federal government and the states share concurrent power to tax; local jurisdictions’ authority to tax is determined by state law and varies widely. My focus is on state taxes because sugary beverage taxes have been mostly proposed by state governments.3 All 50 states and the District of Columbia impose excise taxes on cigarettes, and their amounts have gradually increased.4 In 2011, the mean tax rate among all states was $1.46; the lowest state cigarette excise tax was $0.17 per pack, and the highest was $4.35 per pack.4 Such taxes are partially credited for reducing youth smoking initiation and cigarette consumption while simultaneously decreasing the total amount of cigarettes consumed by persistent users.2 Although high taxes have been proven to deter consumption, they are not acting alone.2 The combination of price increases and other restrictions, such as indoor smoking bans and limits on marketing, have resulted in changes to social norms and a steady decline in smoking rates.Proponents of sugary beverage excise taxes do not suggest that price increases alone will terminate consumption or reverse obesity trends.1 Additional policy options that align with a sugary beverage taxation strategy include removal from schools, mandated serving size restrictions, educational campaigns, retail marketing strategies, and age limits to purchase particularly harmful products such as energy drinks. However, for the tax component of this policy portfolio to be effective, it must actually increase the price of the product to a level that deters consumption. Therefore, it must be assessed at more than a negligible amount and be passed through to consumers. In light of some differences and similarities between sugary beverage manufacturers and tobacco manufacturers, policymakers should consider complementary laws to ensure that the tax levied is factored into the final retail price of the product. Two such laws—minimum price mandates and prohibitions on coupons and discounting—are paramount to the policy discussion.     

Health care evaluation, utilitarianism and distortionary taxes

Cost Utility Analysis (CUA) and Cost Benefit Analysis (CBA) are methods to evaluate allocations of health care resources. Problems are raised for both methods when income taxes do not meet the first best optimum. This paper explores the implications of three ways that taxes may fall short of this ideal. First, taxes may be distortionary. Second, they may be designed and administered without reference to information that is used by providers of health care. Finally, the share of tax revenue that is devoted to health care may be suboptimal. The two methods are amended to account for these factors.     

Taxing Junk Food to Counter Obesity

We examined the advantages and disadvantages of implementing a junk food tax as an intervention to counter increasing obesity in North America.Small excise taxes are likely to yield substantial revenue but are unlikely to affect obesity rates. High excise taxes are likely to have a direct impact on weight in at-risk populations but are less likely to be politically palatable or sustainable.Ultimately, the effectiveness of earmarked health programs and subsidies is likely to be a key determinant of tax success in the fight against obesity.In response to rapidly increasing obesity in North America, health researchers and policymakers are considering novel approaches to counter the growth of this epidemic.1 The divergence between energy intake and expenditure has widened since 1970,2 with a steady increase in daily calorie intake leading scientists and researchers to suggest targeting food consumption as a means of addressing the obesity epidemic. One such approach is now gaining momentum while generating heated debates in and outside the scientific community: a tax on unhealthy foods has been proposed to help reduce their consumption. We consider the implications of implementing 2 types of junk food tax (a nutrient tax and a food and beverage category tax) and provide an overview of arguments in favor of and against their institution. Ethical concerns must be considered along with the current state of scientific evidence about obesity and the efficacy of taxes for behavior change. We have identified significant knowledge gaps that provide direction for future research.     

现代医院人才素质要求与人力资本增值途径

现代医院的发展，对人才的素质也提出了新的要求。现代医院人才应该拥有诚信的品德和对生活充满激情；具有广泛的知识面和扎实的理论知识；解决实际问题的能力和创新能力；良好的沟通能力和亲和力；良好的学习能力和信念传播能力；良好的社会适应能力和协作精神等。要做到这些就要设法使自己的价值得到增值，其主要途径有：在岗位上学习；参加继续医学教育；参加学历学位教育；进修学习；参加科研与创新活动以及参加团队公益活动等。