State-Level Community Benefit Regulation and Nonprofit Hospitals' Provision of Community Benefits

Do nonprofit hospitals provide enough community benefits to justify their tax exemptions? States have sought to enhance nonprofit hospitals' accountability and oversight through regulation, including requirements to report community benefits, conduct community health needs assessments, provide minimum levels of community benefits, and adhere to minimum income eligibility standards for charity care. However, little research has assessed these regulations' impact on community benefits. Using 2009-11 Internal Revenue Service data on community benefit spending for more than eighteen hundred hospitals and the Hilltop Institute's data on community benefit regulation, we investigated the relationship between these four types of regulation and the level and types of hospital-provided community benefits. Our multivariate regression analyses showed that only community health needs assessments were consistently associated with greater community benefit spending. The results for reporting and minimum spending requirements were mixed, while minimum income eligibility standards for charity care were unrelated to community benefit spending. State adoption of multiple types of regulation was consistently associated with higher levels of hospital-provided community benefits, possibly because regulatory intensity conveys a strong signal to the hospital community that more spending is expected. This study can inform efforts to design regulations that will encourage hospitals to provide community benefits consistent with policy makers' goals.

Using reporting requirements to improve employer wellness incentives and their regulation

Employer interest in offering financial incentives for healthy behaviors has been increasing. Some employers have begun to tie health plan-based rewards or penalties to standards involving tobacco use or biometric measures such as body mass index. The Patient Protection and Affordable Care Act attempts to strike a balance between the potential benefits and risks of wellness incentive programs by permitting these incentives but simultaneously limiting their use. Evidence about the implications of the newest generation of incentive programs for health, health costs, and burdens on individual employees will be critical for informing both private and public decision makers. After describing the many pieces of information that would be valuable for assessing these programs, this article proposes more narrowly targeted reporting requirements that could facilitate incentive program development, evaluation, and oversight.

Multihospital system membership and patient treatments, expenditures, and outcomes

OBJECTIVE

To determine the relationship between hospital membership in systems and the treatments, expenditures, and outcomes of patients.

DATA SOURCES

The Medicare Provider Analysis and Review dataset, for data on Medicare patients admitted to general medical-surgical hospitals between 1985 and 1998 with a diagnosis of acute myocardial infarction (AMI); the American Hospital Association Annual Survey, for data on hospitals.

STUDY DESIGN

A multivariate regression analysis. An observation is a fee-for-service Medicare AMI patient admitted to a study hospital. Dependent variables include patient transfers, catheterizations, angioplasties or bypass surgeries, 90-day mortality, and Medicare expenditures. Independent variables include system participation, other admission hospital and patient traits, and hospital and year fixed effects. The five-part system definition incorporates the size and location of the index admission hospital and the size and distance of its partners.

PRINCIPAL FINDINGS

While the effects of multihospital system membership on patients are in general limited, patients initially admitted to small rural system hospitals that have big partners within 100 miles experience lower mortality rates than patients initially admitted to independent hospitals. Regression results show that to the extent system hospital patients experience differences in treatments and outcomes relative to patients of independent hospitals, these differences remain even after controlling for the admission hospital's capacity to provide cardiac services.

CONCLUSIONS

Multihospital system participation may affect AMI patient treatment and outcomes through factors other than cardiac service offerings. Additional investigation into the nature of these factors is warranted.

Hospital-physician affiliations and patient treatments, expenditures, and outcomes

OBJECTIVE

To determine the relationship between hospital-physician affiliations and the treatments, expenditures, and outcomes of patients.

DATA SOURCES

Sources include the Medicare Provider Analysis and Review dataset, the American Hospital Association (AHA) Annual Survey, and the Area Resource File (ARF).

STUDY DESIGN

A multivariate regression analysis of the relationship between hospital-physician affiliations (such as physician-hospital organizations [PHOs] or salaried employment) and the treatment of Medicare patients with a diagnosis of acute myocardial infarction admitted to general medical-surgical hospitals between 1994 and 1998. Dependent variables include whether the patient received a catheterization or angioplasty or bypass surgery; whether a patient was readmitted, or died within 90 days of initial admission; and expenditures. Independent variables include patient, admission hospital, and market characteristics, as well as hospital and year fixed effects.

PRINCIPAL FINDINGS

The integrated salary model form of hospital-physician affiliation is associated with slightly higher procedure rates, and higher patient expenditures. At the same time, there is little evidence that hospital-physician affiliations in the aggregate have had any measurable impact on patient treatment or outcomes.

CONCLUSIONS

The limited effect of hospital-physician affiliations on patient outcomes is consistent with previous research showing that affiliations have not much changed the nature of health care delivery. However, the finding that the integrated salary model is associated with higher treatment intensity suggests that affiliations may have had some impact on patients, and could have more in the future.

Effects of acitretin on the liver

BACKGROUND

Therapy with aromatic retinoids for psoriasis is associated with abnormal liver function test findings and toxic hepatitis (in 1.5% of patients).

OBJECTIVE

Our purpose was to determine the safety of acitretin with respect to liver function, on the basis of biopsy.

METHODS

We treated 128 adults (with chronic, stable psoriasis) with oral acitretin (25-75 mg/day) for four 6-month intervals in a prospective, open-label, 2-year multicenter study. Liver biopsies were performed before and after study completion (2 years).

RESULTS

Eighty-three available pairs of pretreatment and posttreatment liver biopsies demonstrated no change in 49 patients (59%), improvement in 20 (24%), and worsening in 14 (17%). Of these 14 patients with decrements in biopsy status, most changes were mild. There was no correlation between liver function test abnormalities or cumulative acitretin dose and changes in liver biopsy status.

CONCLUSION

Acitretin therapy elicited no biopsy-proven hepatotoxicity in this prospective 2-year study. These findings suggest that periodic liver biopsy may not be necessary with acitretin treatment.

A capitated model for a cross-section of severely mentally ill clients: hospitalization

Hospitalization outcomes are examined in a three year random assignment controlled study of two capitated Integrated Service Agencies (ISAs) in California. Study participants were a cross-section of severely mentally ill clients. Using the flexibility of capitated funding, the urban ISA reduced inpatient length of stay and days, but not admissions. Elements of the capitated ISA model worked together to produce clinically appropriate and less costly use of inpatient services. At the rural ISA, admissions were reduced substantially during the first two years of the demonstration but not costs.

A capitated model for a cross-section of severely mentally ill clients: employment outcomes

Employment outcomes are examined in a three year controlled study of two Integrated Service Agencies (ISAs) for a cross-section of severely mentally ill clients. At each site significantly more ISA members than comparison clients obtained some paid employment. At the urban site the difference was dramatic: 73 vs 15 percent worked during the study period, and 29 percent of the ISA clients worked competitively. The significant but still limited ISA results argue for increased employment opportunities for all seriously mentally ill clients.

Mental health costs, other public costs, and family burden among mental health clients in capitated integrated service agencies

This article explores the cost implications of the capitated integrated service agency (ISA) model for persons with severe and persistent mental illness. Two demonstration sites in California were chosen for a randomized comparison between an ISA model and usual care under the existing county service system. Each ISA demonstration program assumed fiscal and service responsibility for approximately 100 clients. Cost information was collected during a 3-year study period. The capitated ISAs reduced the previously skewed distribution of resources to clients and reduced family economic burden (in one site). However, they did not reduce law enforcement, health, and other nontreatment public costs. Although capitated funding enabled programmatic effectiveness and the shifting of services toward rehabilitation, it did not itself ensure such results.

Client outcomes in a three-year controlled study of an integrated service agency model

OBJECTIVE

In a three-year controlled study, two California integrated service agency demonstration programs that combined structural and program reforms were tested to see if they produced improved outcomes for a cross-section of clients with severe and persistent mental illness.

METHODS

Clients at an urban site and a rural site were randomly assigned to an integrated service agency program or to a comparison group who received the usual services. Data on client outcomes, were drawn from databases and client and family interviews.

RESULTS

Compared with the comparison groups, clients served by the integrated service agencies had less hospital care, greater workforce participation, fewer group and institutional housing arrangements, less use of conservatorship, greater social support, more leisure activity, less family burden, and greater client and family satisfaction. Clients in the urban demonstration program, but not those in the rural program, did better than the comparison group on measures of financial stability, personal well-being, and friendship. At the urban site, 72.6 percent of clients participated in the work force during the three-year study period, compared with 14.6 percent of the clients in the comparison group. No differences were found at either site in rates of arrest and conviction and in self-reported ratings of self-esteem, symptoms, medication compliance, homelessness, and criminal victimization. The capitated costs for demonstration clients were much higher than the costs for services used by comparison clients.

CONCLUSIONS

Three-year outcomes for a cross-section of clients with severe mental illness in the integrated service agencies were broadly favorable, but costs of services for those clients were high relative to costs for clients receiving the current standard of care.

Family care related to alpha-fetoprotein screening

A family's coping repertoire may be challenged when the result of a standard prenatal maternal serum alpha-fetoprotein screening is not within a normal range. Abnormal screening results can cause families to experience anxiety and confusion at a time when they may need to make difficult decisions. The nurse's role is to provide information and emotional support and to coordinate health care services for optimal family coping.

Client outcomes in two model capitated integrated service agencies

OBJECTIVE

Client outcomes for the first year of a three-year study were measured in two integrated service agencies (ISAs) for severely mentally ill persons to test the effectiveness of a model combining financing reform (consolidated funding and capitation) with an assertive continuous treatment team approach.

METHODS

Clients referred to pilot ISAs at an urban and a rural site in California were randomly assigned to the ISA programs or to comparison groups receiving usual services. Objective data from clients' records as well as subjective information from interviews were compared.

RESULTS

At both sites, demonstration clients' participation in the work force was significantly higher than that of the comparison groups. At the urban ISA, clients' participation in the work force rose from a baseline rate of 11 percent to 36 percent. Both ISAs decreased use of hospital care, particularly the rural ISA, which reduced admissions from a baseline rate of 40 percent to 21 percent in the study year. Both ISAs retained clients in treatment with significantly more success than did comparison programs, and urban ISA clients reported participating in more leisure and social activities than did clients in the comparison group. No differences were found at either site in rates of long-term hospitalization, arrest, or conviction or in measures of self-esteem, symptomatology, substance use, homelessness, or quality of life.

CONCLUSIONS

After 12 months of a 36-month program, demonstration clients spent less time in hospitals, were more likely to have worked for pay, and were more likely to have remained in treatment.

A clinical trial of fiberoptic phototherapy vs conventional phototherapy

We conducted a randomized, controlled trial to compare fiberoptic phototherapy with conventional phototherapy in healthy jaundiced newborns with birth weights greater than 2500 g. Twelve patients received fiberoptic phototherapy and 14 patients received conventional phototherapy. There were no significant differences between the groups with respect to birth weight, gestational age, feeding method, presence of hemolytic disease, hematocrit, reticulocyte count, or initial serum bilirubin level. Measured irradiance at 425 to 475 nm for conventional phototherapy was greater than that of fiberoptic phototherapy (9.2 +/- 0.9 microW/cm2 per nanometer vs 8.2 +/- 1.2 microW/cm2 per nanometer). Both types of phototherapy lowered the level of serum bilirubin after 18 hours of therapy (fiberoptic group, from 231 +/- 29 to 210 +/- 24 mumol/L; conventional group, from 231 +/- 21 to 188 +/- 26 mumol/L), but the mean serum bilirubin level was lower after 18 hours of therapy in the conventional phototherapy group (188 +/- 26 vs 210 +/- 24 mumol/L). There were no side effects in either group of newborns. Both methods of phototherapy decreased the serum bilirubin level, but conventional phototherapy did so more effectively, probably because of its greater irradiance.