The Policy Alliance Between Hospitals and Debt Collection Agencies: Content Analysis of Public Comments on Regulations on Billing and Collections

Significant debate persists about the obligations of nonprofit hospitals toward low-income patients. Many issues pertaining to this subject were discussed during the rulemaking process following the passage of the Affordable Care Act of 2010, which set forth rules for hospital billing and collection. In public comments, hospitals, debt collectors, and patient advocates debated what constituted "reasonable efforts" to determine whether a patient qualified for hospital financial assistance before resorting to extraordinary collection actions including lawsuits, wage garnishments, and adverse credit reporting. This study analyzes public comments to the proposed Internal Revenue Service rule on section 501(r)(6). After an initial review of the data, 5 commonly mentioned issues were identified. Respondents were organized into commenter types, and the opinion of each respondent to each issue was coded by 2 separate reviewers. Discrepancies between reviewer determinations were resolved by consensus during follow-up discussions. This analysis revealed a set of common concerns: whether reporting delinquent medical debt to credit bureaus and selling debt to third party buyers should be considered extraordinary collection actions; whether hospitals should be able to use presumptive eligibility to rule patients either eligible or ineligible for financial assistance; and whether hospitals should be held legally liable for the actions of third-party debt collectors. Hospitals and debt collection agencies were allied on most issues, particularly in their shared belief that reporting debt to credit bureaus and selling debt to third parties should not be tightly regulated. Patient advocacy organizations and hospitals had divergent opinions on most issues. The alliance of hospitals and debt collectors in advocating for fewer regulations around collections is part of a history of hospital lobbying to maintain tax-exemption with fewer charity care mandates. This alignment helps explain why third-party debt collection agencies, and aggressive collection tactics, have become commonplace in hospital billing.

Hospital Community Benefit Reporting: How Group Reporting Practices Limit Accountability

OBJECTIVE

To identify the prevalence of group reporting of hospital community benefit efforts to the Internal Revenue Service (IRS) and understand hospital and community characteristics associated with this practice.

DESIGN

The study was based on data collected from publicly available community benefit reports from 2010 to 2019, as well as secondary data from the 2020 American Hospital Association (AHA) Annual Survey. The sample was drawn from the entire nonprofit US hospital population reporting community benefit activities. The analytic plan employed descriptive statistics and bivariate analysis.

SETTING

The United States.

PARTICIPANTS

All data are self-reported by US hospitals, either through the publication of community benefit reports (IRS Form 990 Schedule H) or a response to the AHA Annual Survey.

MAIN OUTCOME MEASURES

Analyzed variables include whether a hospital reported its community benefit expenditures individually or as a group member; community benefit spending as a percentage of hospital operating expenses; and whether the hospital was part of a multihospital system, with consideration of hospital and community characteristics.

RESULTS

Between 2010 and 2019, more than 40% of hospitals participated in group reporting, with most doing so consistently. System membership and hospital size were significantly and positively tied to group reporting, with state community benefit policy tied to the lower prevalence of group reporting.

CONCLUSIONS

The high prevalence of group reporting limits accountability to communities and restricts an accurate assessment of community benefit expenditures, counter to policy intentions. Stakeholders should consider what modifications to reporting rules could be made to promote transparency and to ensure that the effects of community benefit policies align with intentions.

When States Mandate Hospital Community Benefit Reports, Provision Increases

GOAL

We examined the variation in community benefit and charity care reporting standards mandated by states to determine whether state-mandated community benefit and charity care reporting is associated with greater provision of these services.

METHODS

We used 2011-2019 data from IRS Form 990 Schedule H for 1,423 nonprofit hospitals to create a sample of 12,807 total observations. Random effects regression models were used to examine the association between state reporting requirements and community benefit spending by nonprofit hospitals. Specific reporting requirements were analyzed to determine whether certain requirements were associated with increased spending on these services.

PRINCIPAL FINDINGS

Nonprofit hospitals in states that required reports spent a higher percentage of total hospital expenditures on community benefits (9.1%, SD = 6.2%) compared to states without these requirements (7.2%, SD = 5.7%). A similar association between the percentage of charity care and total hospital expenditures (2.3% and 1.5%) was found. The greater number of reporting requirements was associated with lower levels of charity care provision, as hospitals allocated more resources to other community benefits.

PRACTICAL APPLICATIONS

Mandating the reporting of specific services is associated with greater provision of certain specific services, but not all. A concern is that when many services must be reported, the provision of charity care might be reduced as hospitals choose to allocate their community benefit dollars to other categories. As a result, policymakers may want to focus their attention on the services they most want to prioritize.

One Decade Later: The Generalizability, Diversity, and Inclusion of Community Health Needs Assessments

CONTEXT

The 2010 Patient Protection and Affordable Care Act aimed to reduce health disparities and change medicine to be more community-driven. To maintain tax-exempt status, hospitals must complete a Community Health Needs Assessment (CHNA) every 3 years. This assessment must ( a ) integrate input from individuals the community serves, ( b ) make the report publicly assessable, and ( c ) adopt an implementation strategy based on community health needs identified in the assessment. However, there is little information on how representative CHNAs are of the community.

DESIGN

A content analysis was performed on a random sample of CHNA reports.

SETTING

This investigation examined nonprofit hospitals across the United States.

OBJECTIVES

This investigation analyzed the quality of CHNAs and described existing CHNA practices through 4 means: (1) identified the type of data included; (2) examined the frequency in the methods of data collection; (3) understood how representative those data are of the hospital's service region; and (4) explored to what extent the hospital addressed diversity and inclusion such as through recruitment.

METHODS

A stratified random sample was drawn of CHNAs published in the past 3 years (n = 450 reports). The sample was stratified by the US Department of Agriculture's Rural-Urban Continuum codes to balance hospital representation from metro and nonmetro areas.

RESULTS

A series of dependent t tests revealed that these hospitals' reports represented a significantly more female, White, college-educated, and older population than the service area. In addition, only 3.12% of hospitals collected primary youth data. Finally, results also found that survey recruitment was not inclusive of individuals who did not have Internet access, could not read, or did not speak English fluently.

Understanding the relationship between nonprofit hospital community benefit spending and system membership: An analysis of independent hospital acquisitions

The Internal Revenue Service (IRS) requires nonprofit hospitals to report community benefit spending to justify their nonprofit tax exemption. We examined whether nonprofit hospital acquisitions influence the amount and type community benefit spending. We analyzed 2011-2018 data on urban, nonprofit hospitals. The analysis dataset included 57 hospitals that were acquired and a matched control group. We estimated difference-in-differences specifications to measure the effect of acquisitions on total community benefit spending, and three subcategories - clinical, population health, and other spending types. We found that acquisitions led to decreased population health spending (-$0.32 million, p < 0.01) and other spending categories (-$1.5 million, p < 0.05), but no significant change in total or clinical spending. If the acquirer was located out-of-state, total community benefit spending declined by $2.4 million (p < 0.10). Our findings support the need for community benefit spending to be considered, along with quality, efficiency, and prices, when evaluating the welfare impact of acquisitions.

Characteristics of US hospitals using extraordinary collections actions against patients for unpaid medical bills: a cross-sectional study

OBJECTIVE

This study aims to characterise and evaluate the largest 100 hospitals in the USA that have adopted aggressive collection tactics to pursue patients with unpaid medical bills, such as lawsuits, wage garnishments and liens.

DESIGN

Cross-sectional study.

SETTING

We examined state and county court record systems to measure the magnitude and prevalence of these practices at the largest 100 hospitals in the UA between 1 January 2018 and 31 July 2020.

MAIN OUTCOMES MEASURES

The main outcome of this study was the number of lawsuits, wage garnishments and liens. A secondary outcome was the characterisation of a hospital's safety, charitability, size and financial practices.

RESULTS

Between 1 January 2018 and 31 July 2020, 26 hospitals filed 38 965 court actions (lawsuits, wage garnishments and liens) against patients for unpaid medical debt. For 16 of 26 hospitals, the dollar amount pursued in the court claim was available for 100% of cases, totalling US$71.8 million. The average aggregate amount sought by hospital lawsuits during the study period was US$4.5 million. Three hospitals filed US$56.2 million in amounts pursued in court, or 78.3% of the total amount pursued by all hospitals in the sample. In the remaining 74 hospitals, the study team did not identify extraordinary collection actions through the court system.

CONCLUSIONS

Standardised medical debt collections best practices and metrics of medical debt collections quality are needed to increase public accountability for hospitals, particularly non-profit hospitals. There is a need to re-evaluate Internal Revenue Service rules pertaining to non-profit hospitals' tax-exempt status to ensure tax-exempt hospitals provide community benefits commensurate with the value of tax exemption.

Shifts in Community Benefits Spending Among Nonprofit Hospitals in Nebraska and 10 Proximate States, 2012 and 2015

CONTEXT

Federal and state policy makers have debated the evolving concept of community benefit and the extent to which nonprofit hospitals are providing benefits to the community in exchange for the tax benefits they receive.

OBJECTIVE

This study compares community benefits spending by nonprofit hospitals in Nebraska and other selected states in both 2012 and 2015. Expenditures are also examined by rural, regional, and urban hospitals within Nebraska.

METHODS

Community benefit expenditure data were taken from Community Benefit Insight and consolidated into the categories of direct patient care, community health improvement initiatives, and health professions education and research.

RESULTS

When community benefit expenditures were compared across 11 states, Nebraska had the highest percentage of expenditures for community health improvement initiatives in both 2012 and 2015. Although community benefit expenditures for the 44 nonprofit hospitals within Nebraska increased from 2012 to 2015, they remained flat as a share of total hospital expenditures. In 2015, 63% of community benefit expenditures were allocated to direct patient care, which represented a 7.3% decrease from 2012. This decline led to greater spending on community health improvement initiatives (3.1%) and health professions education and research (4.2%). Rural, regional, and urban hospitals spent more proportionately on community health improvement initiatives in 2015 than in 2012.

CONCLUSIONS

The shift in community benefit expenditures from direct patient care to community health improvement initiatives and health professions education and research suggests that hospitals are investing in programs with broader community-wide benefits. Nebraska allocates a significantly larger share of its community benefits spending to community health improvement activities than other Great Plains and Midwestern states. Nebraska is in the process of implementing Medicaid expansion, which may shift future community benefits spending decisions.

Prices, Availability and Affordability of Medicines with Value-Added Tax Exemption: A Cross-Sectional Survey in the Philippines

BACKGROUND

Developing countries, such as the Philippines, started implementing policies to improve access to medicines, which is a vital step toward universal healthcare coverage. This study aimed to evaluate the prices, availability and affordability of prescribed medicines for diabetes, hypercholesterolemia and hypertension with the exemption of 12% value-added tax in the Philippines.

METHODS

The prices and availability of 50 medicines were collected in August 2019 from 36 public and 42 private medicine outlets in six regions of the Philippines, following a modified methodology developed by the World Health Organization and Health Action International. Availability is reported as the percentage of outlets in which the surveyed medicine was found at the time of visit. Medicine prices are expressed as median unit prices (MUPs) in Philippine Peso. Affordability is calculated based on the number of days' wages required for the lowest-paid unskilled government worker to purchase a monthly treatment.

RESULTS

The mean availability of surveyed medicines was low in both public and private sectors, with 1.3% for originator brands (OBs) and 25.0% for lowest-priced generics (LPGs) in public outlets, and 34.7% and 35.4% in private outlets, respectively. The MUP of medicines were higher in private outlets, and OBs have higher unit price compared to the generic equivalents. Treatments with OBs were unaffordable, except for gliclazide, but the affordability of most LPGs is generally good.

CONCLUSION

Access to medicines in both sectors was affected by low availability. High prices of OBs influenced the affordability of medicines even with tax exemption. A review of policies and regulations should be initiated for a better access to medicines in the Philippines.

Priorities for Investing in Community Health Improvement: A Comparison of Decision Makers in Public Health, Nonprofit Hospitals, and Community Nonprofits

CONTEXT

As a result of additional requirements for tax exemption, many nonprofit hospitals have become more actively involved in community health improvement. There is an open question, however, as to how decision makers in hospitals decide which kind of improvement projects should receive priority and how hospital managers' priorities compare with those of decision makers in public health agencies and community-based nonprofits.

OBJECTIVE

To understand the priorities that guide decision makers in public health, nonprofit hospitals, and community nonprofits when allocating resources to community health projects.

DESIGN

We conducted an online survey with a discrete choice experiment, asking respondents to choose between different types of community health projects, which varied along several project characteristics. Respondents included managers of community health and community benefit at nonprofit hospitals (n = 225), managers at local public health departments (n = 200), and leaders of community nonprofits (n = 136). Respondents were located in 47 of 50 US states. A conditional logit model was used to estimate how various project characteristics led to greater or lesser support of a given health project. Open-ended questions aided in interpretation of results.

RESULTS

Respondents from all 3 groups showed strong agreement on community health priorities. Projects were more likely to be selected when they addressed a health issue identified on community health needs assessment, involved cross-sector collaboration, or were supported by evidence. Project characteristics that mattered less included the time needed to measure the project's impact and the project's target population.

CONCLUSION

Elements often considered central to community health, such as long-term investment and prioritizing vulnerable populations, may not be considered by decision makers as important as other aspects of resource allocation. If we want greater priority for ideas such as health equity and social determinants of health, it will take a concerted effort from practitioners and policy makers to reshape expectations.

The Evolution of Community Benefit: Perspective on Progress Toward Purpose

To maintain exemption from federal taxes, non-profit hospitals in the USA are required to contribute to their communities an amount comparable to the taxes they otherwise would have paid. Since 2008, non-profit hospitals have had to file Form 990 Schedule H with the Internal Revenue Service (IRS) to document their “Community Benefit” (CB) activities. The purpose of this article is to present an overview of the evolution of hospitals' engagement with their communities and to examine how the policy enforced by the IRS has evolved. The IRS has not made explicit the assumptions underlying the CB policy. As a result, the evidence about the impact of CB policy and CB activities on the health of a community is sparse. Non-profit hospitals are spending millions of dollars in CB activities and reporting requirements annually, but if and how these expenses contribute to a community's health and well-being are unclear. Conceptual frameworks, such as logic models or Collective Impact models, could be used to explicate the assumed relationships. As the field has evolved and grown more complex, identifying and measuring the contributions of a single hospital or single program to the health status of a community have become more challenging. Collaboration—promoted by the IRS and CDC—has increased these challenges. Until assumptions about relationships are made explicit and tied to measurable goals, non-profit hospitals must continue to comply with IRS requirements but should use their own targets, metrics, and evaluations to ensure that the resources devoted to CB programs are being used cost-effectively.

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.

Public Health and Politics: Using the Tax Code to Expand Advocacy

Protecting the public's health has always been an inherently political endeavor. The field of public health, however, is conspicuously and persistently absent from sustained, sophisticated engagement in political processes, particularly elections, that determine policy outcomes. This results, in large part, from widespread misunderstanding of rules governing how, and how much, public advocates working in tax-exempt organizations can participate in public policy development. This article briefly summarizes the rules governing public policy engagement by exempt organizations. It then describes different types of exempt organizations, and how they can work together to expand engagement. Next, it identifies several key mechanisms of policy development that public health advocates could influence. Finally, it suggests some methods of applying the tax rules to increase participation in these arenas.

Maybe the ACA Is Here To Stay, But Employers Wish That Cadillac Tax Would Go Away

Clinton has come out against the Cadillac tax, but what will replace the revenue? If the ACA is repealed, House Republicans have proposed capping the tax exemption for health benefits as a way to curb the appetite for expensive health care benefits.

A Review of Tools to Assist Hospitals in Meeting Community Health Assessment and Implementation Strategy Requirements

Recent changes in U.S. national policies and regulations have created an opportunity for meaningful collaborations to take place between health systems, public health departments, and social service organizations. For medical systems, and particularly tax-exempt hospitals, new requirements include community health assessments (CHAs) and implementation strategies to address identified health needs. Individuals and groups responsible for meeting the new CHA and implementation strategy requirements may be unsure about the best ways to achieve specific aspects of the CHA process. In this report, we provide an in-depth review and rating of tools developed by public health and community experts that cover the steps necessary to meet the new requirements. A team of three community and public health experts and the authors developed a rating sheet based on a well-known community health improvement process model and on the steps in the new requirements to identify and systematically rate nine comprehensive tools. The ratings and recommendations provide a guide for hospitals in choosing tools that will best assist them in meeting the new requirements.

The Relationship Between Hospital Value-Based Purchasing Program Scores and Hospital Bond Ratings

Tax-exempt hospitals and health systems often borrow long-term debt to fund capital investments. Lenders use bond ratings as a standard metric to assess whether to lend funds to a hospital. Credit rating agencies have historically relied on financial performance measures and a hospital's ability to service debt obligations to determine bond ratings. With the growth in pay-for-performance-based reimbursement models, rating agencies are expanding their hospital bond rating criteria to include hospital utilization and value-based purchasing (VBP) measures. In this study, we evaluated the relationship between the Hospital VBP domains--Clinical Process of Care, Patient Experience of Care, Outcome, and Medicare Spending per Beneficiary (MSPB)--and hospital bond ratings. Given the historical focus on financial performance, we hypothesized that hospital bond ratings are not associated with any of the Hospital VBP domains. This was a retrospective, cross-sectional study of all hospitals that were rated by Moody's for fiscal year 2012 and participated in the Centers for Medicare & Medicaid Services' VBP program as of January 2014 (N = 285). Of the 285 hospitals in the study, 15% had been assigned a bond rating of Aa, and 46% had been assigned an A rating. Using a binary logistic regression model, we found an association between MSPB only and bond ratings, after controlling for other VBP and financial performance scores; however, MSPB did not improve the overall predictive accuracy of the model. Inclusion of VBP scores in the methodology used to determine hospital bond ratings is likely to affect hospital bond ratings in the near term.

Keeping step with IRS guidance on requirements for tax-exempt hospitals

Section 501(r) of the Internal Revenue Code, enacted as part of the Affordable Care Act, requires that section 501(c)(3) hospitals conduct community health needs assessments (CHNAs) every three years. Proposed regulations issued in April 2013 provide guidance on the CHNA requirement and other issues arising under section 501(r). The proposed regulations generally supersede the guidance provided in Notice 2011-52, although a transition period is provided. Hospitals can generally rely on the proposed regulations until final regulations are issued.

The Affordable Care Act and community benefit: a mandate Catholic health care can (partly) embrace

The 2010 Patient Protection and Affordable Care Act (ACA) requires not-for-profit hospitals, including Catholic hospitals, to engage in meaningful community assessment and collaboration efforts in order to maintain their tax-exempt status. Now that the ACA has been upheld by the U.S. Supreme Court, this paper argues that the requirements related to a more robust community engagement process should be embraced by Catholic not-for-profit hospitals and health systems. Apart from the legal requirements under ACA, an equally persuasive moral mandate to engage in community-level assessment and action exists in the ethical tradition of Catholic health care, particularly in the notions of the common good, preferential option for the poor, and subsidiarity. This paper examines the compelling nature of these moral norms in light of the dual goals of improving overall community health and reducing health disparities among vulnerable populations. It concludes with the examination of one model of community collaboration: Mobilizing for Action through Planning and Partnerships (MAPP).

Financing strategic healthcare facilities: the growing attraction of alternative capital

Community health system leaders often dismiss use of alternative capital to finance strategic facilities as being too expensive and less strategically useful, preferring to follow historical precedent and use tax-exempt bonding to finance such facilities. Proposed changes in accounting rules should cause third-party-financed facility lease arrangements to be treated similarly to tax-exempt debt financings with respect to the income statement and balance sheet, increasing their appeal to community health systems. An in-depth comparison of the total costs associated with each financing approach can help inform the choice of financing approaches by illuminating their respective advantages and disadvantages.

Today's trends in capital financing

A health system's approach to capital access in the coming year should include an in-depth analysis of different financing options, including: Tax-exempt fixed rate bonds. Tax-exempt variable rate bonds. Taxable bonds. Direct purchases. New financing products.

Provision of community benefits by tax-exempt U.S. hospitals

BACKGROUND

The Patient Protection and Affordable Care Act (ACA) requires tax-exempt hospitals to conduct assessments of community needs and address identified needs. Most tax-exempt hospitals will need to meet this requirement by the end of 2013.

METHODS

We conducted a national study of the level and pattern of community benefits that tax-exempt hospitals provide. The study comprised more than 1800 tax-exempt hospitals, approximately two thirds of all such institutions. We used reports that hospitals filed with the Internal Revenue Service for fiscal year 2009 that provide expenditures for seven types of community benefits. We combined these reports with other data to examine whether institutional, community, and market characteristics are associated with the provision of community benefits by hospitals.

RESULTS

Tax-exempt hospitals spent 7.5% of their operating expenses on community benefits during fiscal year 2009. More than 85% of these expenditures were devoted to charity care and other patient care services. Of the remaining community-benefit expenditures, approximately 5% were devoted to community health improvements that hospitals undertook directly. The rest went to education in health professions, research, and contributions to community groups. The level of benefits provided varied widely among the hospitals (hospitals in the top decile devoted approximately 20% of operating expenses to community benefits; hospitals in the bottom decile devoted approximately 1%). This variation was not accounted for by indicators of community need.

CONCLUSIONS

In 2009, tax-exempt hospitals varied markedly in the level of community benefits provided, with most of their benefit-related expenditures allocated to patient care services. Little was spent on community health improvement.

The role of non-operating income in community benefit provision by not-for-profit hospitals

Not-for-profit hospitals are under increased public scrutiny for providing what some view as insufficient levels of community benefit compared to their tax-exempt benefits. One potential driver of community benefit is financial surplus, which arises from both patient care (operating) activities and non-patient care (non-operating) activities. This study addresses the effect of hospitals' non-operating income on not-for-profit hospitals' provision of community benefit. The study sample includes 217 unique not-for-profit, non-governmental, general, acute care hospitals in California between 1997 and 2010 that filed annual reports with the California Office of Statewide Health Planning and Development (OSHPD). We model the effect of hospitals' operating and non-operating incomes on hospitals' community benefit, controlling for observable hospital characteristics such as scale and system membership, local competition, time trends, and hospital fixed effects. Our results indicate that non-operating income has no effect on levels of community benefit provided by not-for-profit hospitals. This finding suggests that not-for-profit hospitals budget for uncompensated care at levels that are prioritized over other potential investments if non-operating income falls, but remain fixed if non-operating income rises.

Not-for-profit hospitals' provision of community benefit: is there a trade-off between charity care and other benefits provided to the community?

BACKGROUND

For decades, not-for-profit hospitals have been required to provide community benefit in exchange for tax exemption. To fulfill this requirement, hospitals engage in a variety of activities ranging from free and reduced cost care provided to individual patients to services aimed at improving the health of the community at large. Limited financial resources may restrict hospitals' ability to provide the full range of community benefits and force them to engage in trade-offs.

OBJECTIVES

We analyzed the composition of not-for-profit hospitals' community benefit expenditures and explored whether hospitals traded off between charity care and spending on other community benefit activities.

METHODS

Data for this study came from Maryland hospitals' state-level community benefit reports for 2006-2010. Bivariate Spearman's rho correlation analysis was used to examine the relationships among various components of hospitals' community benefit activities.

RESULTS

We found no evidence of trade-offs between charity care and activities targeted at the health and well-being of the community at large. Consistently, hospitals that provided more charity care did not offset these expenditures by reducing their spending on other community benefit activities, including mission-driven health services, community health services, and health professions education.

CONCLUSIONS

Hospitals' decisions about how to allocate community benefit dollars are made in the context of broader community health needs and resources. Concerns that hospitals serving a disproportionate number of charity patients might provide fewer benefits to the community at large appear to be unfounded.

Tax needn't be taxing, but in the case of organ donation it might be

Petersen and Lippert-Rasmussen argue that, while a tax credit scheme to encourage organ donation would be costly, the increased number of organs for transplantation would lead to other savings in the healthcare system. In the present work some calculations are provided and it is suggested that, even given optimistic assumptions, the cost to the state of implementing the system as proposed would be high and unlikely to garner the support of politicians and policymakers.

Titmuss revisited: from tax credits to markets

Petersen and Lippert-Rasmussen argue that persons who decide to be organ donors should receive a tax break, and then defend their view against eight possible objections. However, they misunderstand the Titmuss-style concerns that might be raised against their proposal. This does not mean that it should be rejected, but, instead, that when it is reconfigured to meet the Titmuss-style charges against it, they should support legalizing markets in human organs rather than merely offering tax breaks to encourage their donation.

Ethics, organ donation and tax: a reply to Quigley and Taylor

A national opt-out system of post-mortem donation of scarce organs is preferable to an opt-in system. Unfortunately, the former system is not always feasible, and so in a recent JME article we canvassed the possibility of offering people a tax break for opting-in as a way of increasing the number of organs available for donation under an opt-in regime. Muireann Quigley and James Stacey Taylor criticize our proposal. Roughly, Quigley argues that our proposal is costly and, hence, is unlikely to be implemented, while Taylor contests our response to a Titmuss-style objection to our scheme. In response to Quigley, we note that our proposal's main attraction lies in gains not reflected in the figures presented by Quigley and that the mere fact that it is costly does not imply that it is unfeasible. In response to Taylor, we offer some textual evidence in support of our interpretation of Taylor and responds to his favoured interpretation of the Titmuss-style objection that many people seem to want to donate to charities even if they can deduct their donations from their income tax. Finally, we show why our views do not commit us to endorsing a free organ-market.

Tax-exempt bank loans still an option for providers

In evaluating the potential for tax-exempt bank financing, healthcare organizations should carefully consider: Pricing. Loan structure. Security requirements (such as financial covenants and default remedies).

Socio-economic variation in price minimizing behaviors: findings from the International Tobacco Control (ITC) Four Country Survey

This paper examines how socio-economic status (SES) modifies how smokers adjust to changes in the price of tobacco products through utilization of multiple price minimizing techniques. Data come from the International Tobacco Control Policy Evaluation (ITC) Four Country Survey, nationally representative samples of adult smokers and includes respondents from Canada, the United States, the United Kingdom and Australia. Cross-sectional analyses were completed among 8,243 respondents (7,038 current smokers) from the survey wave conducted between October 2006 and February 2007. Analyses examined predictors of purchasing from low/untaxed sources, using discount cigarettes or roll-your-own (RYO) tobacco, purchasing cigarettes in cartons, and engaging in high levels of price and tax avoidance at last purchase. All analyses tested for interactions with SES and were weighted to account for changing and under-represented demographics. Relatively high levels of price and tax avoidance behaviors were present; 8% reported buying from low or untaxed source; 36% used discount or generic brands, 13.5% used RYO tobacco, 29% reported purchasing cartons, and 63% reported using at least one of these high price avoidance behaviors. Respondents categorized as having low SES were approximately 26% less likely to report using low or untaxed sources and 43% less likely to purchase tobacco by the carton. However, respondents with low SES were 85% more likely to report using discount brands/RYO compared to participants with higher SES. Overall, lower SES smokers were 25% more likely to engage in at least one or more tax avoidance behaviors compared to their higher SES counterparts. Price and tax avoidance behaviors are relatively common among smokers of all SES strata, but strategies differed with higher SES groups more likely to report traveling to a low-tax location to avoid paying higher prices, purchase duty free tobacco, and purchase by cartons instead of packs all of which were less commonly reported by low SES smokers. Because of the strategies lower SES respondents are more likely to use, reducing price differentials between discount and premium brands may have a greater impact on them, potentially increasing the likelihood of quitting.

Community benefit activities of private, nonprofit hospitals

The definition of hospital community benefits has been intensely debated for many years. Recently, consensus has developed about one group of activities being central to community benefits because of its focus on care for the poor and on needed community services for which any payments received are low relative to costs. Disagreements continue, however, about the treatment of bad debt expense and Medicare shortfalls. A recent revision of the Internal Revenue Service's Form 990 Schedule H, which is required of all nonprofit hospitals, highlights the agreed-on set of activities but does not dismiss the disputed items. Our study is the first to apply definitions used in the new IRS form to assess how conclusions about the adequacy of nonprofit hospital community benefits could be affected if bad debt expenses and Medicare shortfalls are included or excluded. Specifically, we examine 2005 financial data for California and Florida hospitals. Overall, we find that conclusions about community benefit adequacy are very different depending on which definition of community benefits is used. We provide thoughts on new directions for the current policy debate about the treatment of bad debts and Medicare shortfalls in light of these findings.