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Currently, Polish therapeutic entities are forced to operate in an extremely turbulent environment and pursue two main goals: economic and social. The aim of this article is to diagnose the relationship between profitability and financial liquidity in Polish self-government health care institutions by assessing basic indicators of financial liquidity and profitability. The scope of work covered 1017 self-government independent health care institutions, which systematically published their financial statements for 2016-2018. The subject of the study was to analyze the relationship between the levels of profitability and financial liquidity ratios. The study used statistical and tabular-descriptive methods. On the basis of the obtained results it can be stated that the relation between the return on sales, return on equity and return on assets and liquidity (current, fast and immediate) was positive and the strength of this relation was strong and statistically significant. There was a statistically significant negative correlation between short-term liabilities and the return on sales, assets and equity. The cash conversion cycle has a significant positive impact on profitability (and vice versa). CONCLUSION. Entities that had higher profitability also had a higher degree of liquidity. They were also more efficient in inventory management and paid their liabilities faster. Summarizing the results of the study, it can be concluded that those entities that had higher profitability also had a higher degree of liquidity. They were also more efficient in inventory management and paid their liabilities faster.

Child neurology programs can be net margin generators for children's hospitals. The relative value unit (RVU) expectations for child neurologists are heavily influenced by proceduralists (neurophysiologists, Botox injectors, and so forth) and means in most RVU data sets are not realistic expectations for Evaluation and Management coding, outpatient neurologists. Yet each neurologist has a net revenue/expense ratio of 1.97 for a hospital neurology enterprise, so each of the neurologists generates nearly twice their salary for the hospital. Downstream revenue is even more impressive. Each neurologist generates about $2,000,000.00 in downstream revenue per year.

Introduction: The treatment of cancer patients in Germany is characterized by sectoral separation of the in- and outpatient care accompanied by 2 separate reimbursement systems. By introducing the Guideline of Outpatient Medical Specialist Care in accordance with §116b SGB V (ASV) in 2014, the German legislation empowers office-based physicians and hospitals to jointly provide medical care in the ambulatory setting. Methods: A 1-year period each before and after the introduction of ASV was compared by means of data from the Center for Integrated Oncology Cologne at the University Hospital of Cologne. Only adults with a reliable diagnosis of gastrointestinal tumor (GIT) were considered. Results: Overall, 1,872 cases were considered in the analysis showing significant (p < 0.001) higher median values of revenues across ICD-subgroups for ASV (EUR 427.46) compared to Ambulatory Treatments in Hospitals (EUR 234.21). The exemplary analysis of revenues in neoplasms of the pancreas shows EUR 173.69 on average which are only invoiceable through ASV: flat rate incl. surcharges (EUR 117.79; 68%), structure lump sum (EUR 29.49; 17%), positron-emission tomography (PET)/CT (EUR 13.53; 18%), and ASV consultation hour (EUR 12.89; 7%). Discussion/Conclusion: ASV leads to significant higher revenues across different ICD-subgroups for patients suffering from severe GIT. The collaboration of hospital and office-based physicians ensures patient-centered care with accumulated expertise and avoidance of double examinations. Thus, the inclusion of additional services in the Uniform Value Scale (invoiceable for ASV) is legitimated and enables cost-covering care for the involved parties.

This article examines the relationship between hospital profitability and efficiency. A cross-section of 1317 U.S. metropolitan, acute care, not-for-profit hospitals for the year 2015 was employed. We use a frontier method, stochastic frontier analysis, to estimate hospital efficiency. Total margin and operating margin were used as profit variables in OLS regressions that were corrected for heteroskedacity. In addition to estimated efficiency, control variables for internal and external correlates of profitability were included in the regression models. We found that more efficient hospitals were also more profitable. The results show a positive relationship between profitability and size, concentration of output, occupancy rate and membership in a multi-hospital system. An inverse relationship was found between profits and academic medical centers, average length of stay, location in a Medicaid expansion state, Medicaid and Medicare share of admissions, and unemployment rate. The results of a Hausman test indicates that efficiency is exogenous in the profit equations. The findings suggest that not-for-profit hospitals will be responsive to incentives for increasing efficiency and use market power to increase surplus to pursue their objectives.

Objective We describe our experience in implementing enterprise-wide standardized structured reporting for chest radiographs (CXRs) via change management strategies and assess the economic impact of structured template adoption. Methods Enterprise-wide standardized structured CXR reporting was implemented in a large urban health care enterprise in two phases from September 2016 to March 2019: initial implementation of division-specific structured templates followed by introduction of auto launching cross-divisional consensus structured templates. Usage was tracked over time, and potential radiologist time savings were estimated. Correct-to-bill (CTB) rates were collected between January 2018 and May 2019 for radiography. Results CXR structured template adoption increased from 46% to 92% in phase 1 and to 96.2% in phase 2, resulting in an estimated 8.5 hours per month of radiologist time saved. CTB rates for both radiographs and all radiology reports showed a linearly increasing trend postintervention with radiography CTB rate showing greater absolute values with an average difference of 20% throughout the sampling period. The CTB rate for all modalities increased by 12%, and the rate for radiography increased by 8%. Discussion Change management strategies prompted adoption of division-specific structured templates, and exposure via auto launching enforced widespread adoption of consensus templates. Standardized structured reporting resulted in both economic gains and projected radiologist time saved.

Regulated prices are common in markets for medical care. We estimate the effect of changes in regulated reimbursement prices on volume of hospital care based on a reform of hospital financing in Germany. Uniquely, this reform changed the overall level of reimbursement—with increasing prices for some hospitals and decreasing prices for others—without directly affecting the relative prices for different groups of patients or types of treatment. Based on administrative data, we find that hospitals react to increasing prices by decreasing the service supply and to decreasing prices by increasing the service supply. Moreover, we find some evidence that volume changes for hospitals with different price changes are nonlinear. We interpret our findings as evidence for a negative income effect of prices on volume of care.

Importance Suing patients and garnishing their wages for unpaid medical bills can be a predatory form of financial activity that may be inconsistent with the mission of a hospital. Many hospitals in the state of Virginia were discovered to be suing patients for unpaid medical bills, as first presented in a 2019 research article that launched 2.5 months of media attention on hospital billing practices and a grassroots public demand for hospitals to stop the practice. Objective To evaluate the association of a research publication and subsequent media coverage with the number of hospital lawsuits filed against patients for unpaid medical bills. Design, Setting, and Participants This cross-sectional study of Virginia hospitals that sued patients for unpaid medical bills used an interrupted time series analysis. Data on hospitals suing patients for unpaid medical bills were collected during a preintervention period (June 25, 2018, to June 24, 2019), an intervention period (June 25, 2019, to September 10, 2019), and a postintervention period (September 11, 2019, to September 10, 2020). Exposures Publication of a research article and subsequent media coverage. Main Outcomes and Measures The total number of warrant in debt and wage garnishment lawsuits filed by Virginia hospitals and the frequency of those lawsuits filed before, during, and after the intervention period on a weekly basis. Results A total of 50 387 lawsuits, filed by 67 Virginia hospitals, were included; 33 204 (65.9%) were warrant in debt lawsuits, and 17 183 (34.1%) were wage garnishment lawsuits. From the preintervention period to the postintervention period, there was a 59% decrease in the number of lawsuits filed (from 30 760 lawsuits to 12 510 lawsuits), a 55% decrease in the number of warrant in debt cases filed (from 19 329 to 8651), a 66% decrease in the number of wage garnishments filed (from 11 431 to 3859), and a 64% decrease in the dollar amount pursued in court (from $38 700 209 to $13 960 300). During the study period, 11 hospitals banned the practice of suing patients for unpaid medical bills. The interrupted time series analysis showed a significant decrease of 5% (incidence rate ratio, 0.95; 95% CI, 0.94-0.96) in the total weekly number of lawsuits in the postintervention period. Conclusions and Relevance The findings of this study suggest that research leading to public awareness can shift hospital billing practices.

Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. The benefits surrounding its success internationally include improved quality and patient safety outcomes and increased reimbursement. The premise of CDI is simple: engage clinicians to improve the clinical documentation in the medical record in “real time” so that it is fit for reporting, analysis and reimbursement. Every country has differing healthcare systems and this article has focused on validating the relevancy of CDI for the Australian healthcare environment.

Objective To determine the association of state laws on nonprofit hospital community benefit spending. Design We used multivariate models to estimate the association between different types of state-level community benefit laws and nonprofit hospital community benefit spending from tax filings. Setting All 50 US states. Participants A total of 2421 nonprofit short-term acute care hospital organizations that filled an internal revenue service Form 990 and Schedule H for calendar during years 2009-2015. Results Between 2009 and 2015, short-term acute care hospitals spent an average of $46 billion per year in total, or $20 million per hospital on community benefit activities. Exposure to a state-level community benefit law of any type was associated with an $8.42 (95% confidence interval: 1.20-15.64) per $1000 of total operating expense greater community benefit spending. Spending amounts and patterns varied on the basis of the type of community benefit law and hospital urbanicity. Conclusions State laws are associated with nonprofit hospital community benefit spending. Policy makers can use community benefit laws to increase nonprofit hospital engagement with public health.

The Comprehensive Care for Joint Replacement (CJR) model introduced in 2016 aims to improve the quality and costs of care for Medicare beneficiaries undergoing hip and knee replacements. However, there are concerns that the safety-net hospitals that care for the greatest number of vulnerable patients may perform poorly in CJR. In this study we used Medicare's CJR data to evaluate the performance of 792 hospitals mandated to participate in the first year of CJR. We found that in comparison to non-safety-net hospitals, 42 percent fewer safety-net hospitals qualified for rewards based on their quality and spending performance (33 percent of safety-net hospitals qualified, compared to 57 percent of non-safety-net hospitals), and safety-net hospitals' rewards per episode were 39 percent smaller ($456 compared to $743). Continuation of this performance trend could place safety-net hospitals at increased risk of penalties in future years. Medicare and hospital strategies such as those that reward high-quality care for vulnerable patients could enable safety-net hospitals to compete effectively in CJR.

Background In 2014, Maryland implemented the Global Budget Revenue (GBR) program to reduce unnecessary hospital utilization and contain spending. Little is known about its impact on pediatric health outcomes and high-cost services that are primarily financed by payers other than Medicare. Objective The aim was to examine the impact of the GBR program on neonatal intensive care unit (NICU) admission and infant mortality. Research design We conducted a difference-in-differences analysis comparing changes of NICU admissions and infant mortality in Maryland with changes in 20 comparison states (including DC), before and after implementation of the GBR program. Effects were estimated for all infants and for risk groups defined by birthweight and gestation. Subjects A total of 11,965,997 newborns in Maryland and the comparison states was identified using US birth certificate data from 2011 to 2017. Measures NICU admissions, the infant mortality rate, and the neonatal mortality rate. Results The GBR program was associated with a 1.26 percentage points (-16.8%, P=0.03) decline in NICU admissions over three full years of implementation. Reductions were driven by fewer admissions among moderately low to normal birthweight (1500-3999 g) and moderately preterm to term (32-41 wk) infants. The effects for very-low birthweight and very preterm infants were small and not statistically precise. There was no significant change in infant or neonatal mortality rates. Conclusions Maryland's hospitals reacted to the GBR program by reducing NICU services for infants that did not have clear observed clinical need. Our results suggest that GBR constrained high-cost services, without adversely affecting infant mortality.

Key Points Question Is graduate medical education funding associated with hospital perfomance and patient outcomes? Findings This economic evaluation of 1298 academic hospitals in the US assessed the association between confounder-adjusted graduate medical education funding and hospital financial standing, patient outcomes, and resident academic performance. A statistically significant association was found between higher graduate medical education funding and worse hospital financial standing, reduced patient mortality, and improved resident academic performance. Meaning These findings suggest that graduate medical education funding does not improve the financial standing of hospitals but is associated with improved patient outcomes and resident academic performance., This economic evaluation examines graduate medical education funding, an annual subsidy awarded to academic hospitals, and whether it is associated with a hospital’s financial standing, clinical outcomes, or resident academic performance., Importance Graduate medical education (GME) funding consists of more than $10 billion annual subsidies awarded to academic hospitals to offset the cost of resident training. Critics have questioned the utility of these subsidies and accountability of recipient hospitals. Objective To determine the association of GME funding with hospital performance by examining 3 domains of hospital operations: financial standing, clinical outcomes, and resident academic performance. Design, Setting, and Participants This study is an economic evaluation of all academic centers that received GME funding in 2017. GME funding data were acquired from the Hospital Compare Database. Statistical analysis was performed from May 2016 to April 2020. Exposures GME funding. Main Outcomes and Measures This study assessed the association between GME funding and each aspect of hospital operations. Publicly available hospital financial data were used to calculate a financial performance score from 0 to 100 for each hospital. Clinical outcomes were defined as 30-day mortality, readmission, and complication rates for a set of predefined conditions. Resident academic performance was determined by Board Certification Examination (BCE) pass rates at 0, 2, and 5 years after GME funding was awarded. Confounder-adjusted linear regression models were used to test association between GME funding data and a hospital’s financial standing, clinical outcomes, and resident academic performance. Results The sample consisted of 1298 GME-funded hospitals, with a median (IQR) of 265 (168-415) beds and 32 (10-101) residents per training site. GME funding was negatively correlated with hospitals’ financial scores (β = –7.9; 95% CI, –10.9 to –4.8, P = .001). Each additional $1 million in GME funding was associated with lower 30-day mortality from myocardial infarction (–2.34%; 95% CI, –3.59% to –1.08%, P

Objective We sought to quantify the financial impact of elective surgery cancellations in the United States (US) during COVID-19 and simulate hospitals' recovery times from a single period of surgery cessation. Background COVID-19 in the United States (US) resulted in cessation of elective surgery-a substantial driver of hospital revenue-and placed patients at risk and hospitals under financial stress. We sought to quantify the financial impact of elective surgery cancellations during the pandemic and simulate hospitals' recovery times. Methods Elective surgical cases were abstracted from the Nationwide Inpatient Sample (2016-2017). Time series were utilized to forecast March-May 2020 revenues and demand. Sensitivity analyses were conducted to calculate the time to clear backlog cases and match expected ongoing demand in the post-COVID period. Subset analyses were performed by hospital region and teaching status. Results National revenue loss due to major elective surgery cessation was estimated to be $22.3 billion (B). Recovery to market equilibrium was conserved across strata and influenced by pre- and post-COVID capacity utilization. Median recovery time was 12-22 months across all strata. Lower pre-COVID utilization was associated with fewer months to recovery. Conclusions Strategies to mitigate the predicted revenue loss of $22.3B due to major elective surgery cessation will vary with hospital-specific supply-demand equilibrium. If patient demand is slow to return, hospitals should focus on marketing of services; if hospital capacity is constrained, efficient capacity expansion may be beneficial. Finally, rural and urban non-teaching hospitals may face increased financial risk which may exacerbate care disparities.

The electrosurgical technology category is used widely, with a diverse spectrum of devices designed for different surgical needs. Historically, hospitals are supplied with electrosurgical devices from several manufacturers, and those devices are often evaluated separately; it may be more efficient to evaluate the category holistically. This study assessed the health economic impact of adopting an electrosurgical device-category from a single manufacturer. A budget impact model was developed from a U.S. hospital perspective. The uptake of electrosurgical devices from EES (Ethicon Electrosurgery), including ultrasonic, advanced bipolar, smoke evacuators, and reusable -dispersive electrodes were compared with similar MED (Medical Energy Devices) from multiple manufacturers. It was assumed that an average hospital performed 10,000 annual procedures 80% of which involved electrosurgery. Current utilization assumed 100% MED use, including advanced energy, conventional smoke mitigation options (e.g., ventilation, masks), and single-use disposable dispersive electrode devices. Future utilization assumed 100% EES use, including advanced energy devices, smoke evacuators (i.e., 80% uptake), and reusable dispersive electrodes. Surgical specialties included colorectal, bariatric, gynecology, thoracic and general surgery. Systematic reviews, network meta-analyses, and meta-regressions informed operating room (OR) time, hospital stay, and transfusion model inputs. Costs were assigned to model parameters, and price parity was assumed for advanced energy devices. The costs of disposables for dispersive electrodes and smoke-evacuators were included. The base-case analysis, which assessed the adoption of EES instead of MED for an average U.S. hospital predicted an annual savings of $824,760 ($101 per procedure). Savings were attributable to associated reductions with EES in OR time, days of hospital stay, and volume of disposable electrodes. Sensitivity analyses were consistent with these base-case findings. Category-wide adoption of electrosurgical devices from a single manufacturer demonstrated economic advantages compared with disaggregated product uptake. Future research should focus on informing comparisons of innovative electrosurgical devices.

Despite remarkable academic efforts, why Enterprise Resource Planning (ERP) post-implementation success occurs still remains elusive. A reason for this shortage may be the insufficient addressing of an ERP-specific interior boundary condition, i.e., the multi-stakeholder perspective, in explaining this phenomenon. This issue may entail a gap between how ERP success is supposed to occur and how ERP success may actually occur, leading to theoretical inconsistency when investigating its causal roots. Through a case-based, inductive approach, this manuscript presents an ERP success causal network that embeds the overlooked boundary condition and offers a theoretical explanation of why the most relevant observed causal relationships may occur. The results provide a deeper understanding of the ERP success causal mechanisms and informative managerial suggestions to steer ERP initiatives towards long-haul success.

Due to the COVID-induced global collapse in demand for air travel, the year 2020 was a catastrophic one for the aviation industry. A dramatic drop in operating revenues along with continuing fixed expenses drained the cash reserves of airlines, with consequent risks of financial distress and, potentially, even of bankruptcy. Flag-carriers are a special group in the airline business—they are considered to have privileges in terms of the support given by governments while, on the other hand, are often viewed as having low efficiency and performance. This study aims to estimate for European airlines the interaction effect of being a flag-carrier (flagship) with the relationship between leverage, liquidity, profitability, and the degree of financial distress. Findings obtained from analysing 99 European airlines over a period of ten years, indicate that the negative influence of leverage on financial stability is higher in the case of flag carriers (flagship). The impact of liquidity and profitability on financial health is more positive for flagship than for non-flagship carriers. These findings are not limited to contributing to the existing literature, but also have significant practical implications for executives, managers, and policy makers in the European air transport sector.

The financial viability of rural hospitals has been a matter of serious concern, with ongoing closures affecting rural residents' access to medical services. We examined the financial viability of 1,004 US rural hospitals that had consistent rural status in 2011-17. The median overall profit margin improved for nonprofit critical access hospitals (from 2.5 percent to 3.2 percent) but declined for other hospitals (from 3.0 percent to 2.6 percent for nonprofit non-critical access hospitals, from 3.2 percent to 0.4 percent for for-profit critical access hospitals, and from 5.7 percent to 1.6 percent for for-profit non-critical access hospitals). Occupancy rate and charge markup were positively associated with overall margins: In 2017 hospitals with low versus high occupancy rates had median overall profit margins of 0.1 percent versus 4.7 percent, and hospitals with low versus high charge markups had median overall margins of 1.8 percent versus 3.5 percent. Rural hospital financial viability deteriorated in states that did not expand eligibility for Medicaid and was lower in the South. Rural hospitals that closed during the study period had a median overall profit margin of -3.2 percent in their final year before closure. Policy makers should compare the incremental cost of providing essential services between hospitals and other settings to balance access and efficiency.

Objective The purpose of this research study was to design and pilot a predictive hiring model to improve the hospital's operational vacancy rate and reduce premium pay expenses. Background According to Purcell, the average nursing turnover rate is at 18.2%, and the new-graduate nurse turnover rate is higher at 35%. With turnover rates high for nurses, the importance of recruiting, hiring, and training the new nurse needs to be completed as soon as possible. Often, a nurse manager cannot interview and hire into a position until it is vacated. Premium pay including overtime is typically used to cover the time from the position being vacated until the next nurse is trained. Methods This was a pretest/posttest design with a predictive hiring model intervention. The intervention was a 3-pronged approach that consisted of a strategy for recruiting graduate nurses, hiring to operation vacancy rates, and utilizing a predictive hiring method. Operational vacancy is a calculation to determine if a department has the right amount of hired labor available to work scheduled shifts without having to routinely rely on agency nurses and/or premium pay. These are people ready to work. Results The hospital significantly decreased premium pay and eliminated the use of agency nurses by implementing a predictive hiring model tailored to the department's operational vacancy. Conclusions A predictive model is a useful vehicle in assisting nurse managers to plan and replace positions more quickly. The model needs continued testing to support application beyond the testing site.

Nurse anesthetists can use their creative problem-solving abilities to benefit both their employers and themselves. In an era when healthcare dollars are in short supply and patients who require anesthesia care are living longer (and requiring more procedures with anesthesia), innovative strategies are needed to achieve value and access to anesthesiology services. Leveraging the professional interests of Certified Registered Nurse Anesthetists (CRNAs), the implementation of a flexibility-based compensation structure can optimize overall staffing requirements to meet patient care demands, particularly in the face of recruitment challenges. This unique program, proposed and implemented by CRNAs, is presented as an exemplar that accomplishes multiple professional and financial goals.

The closure of Hahnemann University Hospital, which was announced on June 26, 2019, resulted in the most significant graduate medical education displacement in history, sending over 550 residents to new institutions within a month of the announcement. Over 2,000 physicians, nurses, and staff lost their jobs. While seemingly predictable in retrospect, the closure came as a cataclysmic event to all involved. In this Invited Commentary, a department chair reflects on the lessons learned from these unprecedented circumstances. These lessons cover areas that are not a typical concern for faculty who are focused on teaching their trainees, but are worthy of their attention. Corporate and organizational structure, leadership, and financing of the hospital were critical determining characteristics of the failure. The roles that the Accreditation Council for Graduate Medical Education and the Centers for Medicare and Medicaid Services played in this event were key stabilizers. However, examining their roles in this event offers opportunities to play a more active role in future events and alter how the next massive displacement unfolds, possibly preserving teaching programs. Highly competitive health systems should rethink noncollaborative strategies before allowing struggling institutions to succumb to market forces. Finally, a commitment by a hospital to the mission of academic medicine is a sacred trust with the faculty, trainees, and patients that it serves. It should not be undertaken by any enterprise that is not well resourced and equipped with the knowledge and expertise to meet this most serious of commitments.

BACKGROUND Patient safety and safety culture have received increasing attention from agencies such as the Agency of Healthcare Research and Quality and the Institute of Medicine. Safety culture refers to the fundamental values, attitudes, and perceptions that provide a unique source of competitive advantage to improve performance. This study contributes to the literature and expands understanding of safety culture and hospital performance outcomes when considering electronic health record (EHR) usage. PURPOSE Based on the resource-based view of the firm, this study examined the association between safety culture and hospital quality and financial performance in the presence of EHR. METHODOLOGY/APPROACH Data consist of the 2016 Hospital Survey on Patient Safety, Hospital Compare, American Hospital Association's annual survey, and the American Hospital Association's Information Technology supplement. Our final analytic sample consisted of 154 hospitals. We used a two-part nested regression model approach. RESULTS/CONCLUSION Safety culture has a direct positive relationship with financial performance (operating margin). Furthermore, having basic EHR as compared to not having EHR further enhances this positive relationship. On the other hand, safety culture does not have a direct association with quality performance (readmissions) in most cases. However, safety culture coupled with basic EHR functionalities, compared to not having EHR, is associated with lower readmissions. PRACTICE IMPLICATIONS Hospitals should strive to improve patient safety culture as part of their strategic plan for quality improvement. In addition, hospital managers should consider implementing EHR as a resource that can support safety culture's effect on outcomes such as financial and quality performance indicators. Future studies can examine the differences between basic and advanced EHR presence in relation to safety culture.

The issue of public hospital reform in Turkey was raised in the mid-1980s due to the desire to restrict public expenditures for health care services. In the last 30 years, transformations of public hospitals into health enterprises with administrative and financial autonomy have been attempted in various ways. The process of subjecting public hospitals to reform evolved into the provincial "public hospital unions" model with the Decree Law No. 663 in November 2011. However, this model, which was created to use resources effectively and efficiently in the field of health, was terminated in 2017. The purpose of this study is to review and evaluate the "public hospital union" model of public hospital reform implemented between 2012 and 2017 as an integrated part of reforms in the Turkish health care system and to examine the factors and obstacles that led to the failure of this model. The level of autonomy, in terms of key management functions of unions and hospitals, was analyzed using the toolkit proposed by Chawla et al (1996), and Preker and Harding (2003). In the study, it is asserted that instead of autonomization and decentralization, such organizational reforms result in centralization and political control.

In Germany, there are currently many voices calling for a reform of hospital planning and reimbursement to correct some aberrations of the last decades and to enable the system to cope with future challenges. Some recent political decisions to change the structures of emergency medical services as well as the introduction of mandatory nurse-to-patient ratios and the exclusion of the cost for nursing from the case-based hospital reimbursement represent first steps of a reform, which also affects intensive care and emergency medicine. In this discussion paper a group of intensivists, emergency physicians, medical controllers, and representatives of nurses suggest more far-reaching changes, which can be summarized in 5 points: (1) General hospitals with intensive care units (ICU) and emergency departments (ED) which are part of the emergency medical system should be considered as an element of public service and be planned accordingly. (2) The planning of the intensive care infrastructure should be based on the three levels of emergency medical services to identify hospitals that are system relevant and to define appropriate criteria for structure and quality measures. (3) Hospital reimbursement should consist of a base amount (covering costs for hospital staff, infrastructure plus investments) and case-based fees (covering material costs). (4) To determine the requirements for nurses, physicians, and other medical staff, adequate tools for ICU and ED should be applied. (5) For these purposes as well as for quality management and optimal medical care, hospitals should be provided with a substantially improved IT-infrastructure.

U.S. hospitals have been investing in high-technology medical services as a strategy to improve financial performance. Despite the interest in high-tech medical services, there is not much information available about the impact of high-tech services on financial performance. The aim of this study was to examine the impact of high-tech medical services on financial performance of U.S. hospitals by using the resource-based view of the firm as a conceptual framework. Fixed-effects regressions with 2 years lagged independent variables using a longitudinal panel sample of 3,268 hospitals (2005–2010). It was hypothesized that hospitals with rare or large numbers (breadth) of high-tech medical services will experience better financial performance. Fixed effects regression results supported the link between a larger breadth of high-tech services and total margin, but only among not-for-profit hospitals. Both breadth and rareness of high-tech services were associated with high total margin among not-for-profit hospitals. Neither breadth nor rareness of high-tech services was associated with operating margin. Although breadth and rareness of high-tech services resulted in lower expenses per inpatient day among not-for-profit hospitals, these lower costs were offset by lower revenues per inpatient day. Enhancing the breadth of high-tech services may be a legitimate organizational strategy to improve financial performance, especially among not-for-profit hospitals. Hospitals may experience increased productivity and efficiency, and therefore lower inpatient operating costs, as a result of newer technologies. However, the negative impact on operating revenue should caution hospital administrators about revenue reducing features of these technologies, which may be related to the payer mix that these technologies may attract. Therefore, managers should consider both the cost and revenue implications of these technologies.

Key Points Question Is the Georgia Rural Hospital Tax Credit Program associated with the financial health of participating rural hospitals 2 years after implementation? Findings In this cross-sectional study of 136 hospitals, difference-in-differences analysis found that the tax credit program was associated with increases in program participants’ probability of reporting good or excellent financial strength, which appeared to be driven by an increase in profitability. Meaning These findings suggest that the Georgia Rural Hospital Tax Credit program has improved the financial health of participating rural hospitals., This cross-sectional study examines the association of Georgia’s Rural Hospital Tax Credit Program with the financial health of participating rural hospitals., Importance In 2016, Georgia implemented the Rural Hospital Tax Credit Program, which allows taxpayers to receive a tax credit for contributions to qualifying rural hospitals in the state. Empirical evidence of the program’s association with the viability of the state’s rural hospitals is needed. Objective To examine the association of the tax credit program with the financial health of participating rural hospitals. Design, Setting, and Participants This longitudinal cross-sectional study used hospital financial data from the Centers for Medicare & Medicaid Services for 2015 to 2019. A difference-in-differences analytic approach was used to examine the association of the tax credit program with rural hospital financial health. Study participants included Georgia rural hospitals eligible to participate in the program. Comparison hospitals were selected from the southern states of Alabama, Florida, Mississippi, North Carolina, South Carolina, and Tennessee. Exposures Hospital participation in the Georgia Rural Hospital Tax Credit Program. Main Outcomes and Measures The primary outcome of the study was financial health measured with total margin, days cash on hand, debt-asset ratio, and average age of plant as well as a Financial Strength Index (FSI), which combined the previous measures to assess overall financial strength. Results The analytical sample included a balanced panel of 136 hospitals, with 47 Georgia Rural Hospital Tax Credit Program participants (18 [38%] critical access hospitals; 5 [11%] system affiliated; mean [SD] bed count, 60 [47]; mean [SD] Medicare inpatient mix, 52% [16]) and 89 comparison hospitals (43 [48%] critical access hospitals; 24 [27%] system affiliated; mean [SD] bed count, 52 [41]; mean [SD] Medicare inpatient mix, 67% [18]). Two years after implementation, program participation was associated with a 23% increased probability of good or excellent financial health (b = 0.23; 95% CI, 0.10-0.37; P

About 60% of the US hospitals are not-for-profit and it is not clear how traditional theories of capital structure should be adapted to understand the borrowing behavior of not-for-profit hospitals. This paper identifies important determinants of capital structure taken from theories describing for-profit firms as well as prior literature on not-for-profit hospitals. We examine the differential effects these factors have on the capital structure of for-profit and not-for-profit hospitals. Specifically, we use a difference-in-differences regression framework to study how differences in leverage between for-profit and not-for-profit hospitals change in response to key explanatory variables (i.e. tax rates and bankruptcy costs). The sample in this study includes most US short-term general acute hospitals from 2000 to 2012. We find that personal and corporate income taxes and bankruptcy costs have significant and distinct effects on the capital structure of for-profit and not-for-profit hospitals. Specifically, relative to not-for-profit hospitals: (1) higher corporate income tax encourages for-profit hospitals to increase their debt usage; (2) higher personal income tax discourages for-profit hospitals to use debt; and (3) higher expected bankruptcy costs lead for-profit hospitals to use less debt. Over the past decade, the capital structure of for-profit hospitals has been more flexible as compared to that of not-for-profit hospitals. This may suggest that not-for-profit hospitals are more constrained by external financing resources. Particularly, our analysis suggests that not-for-profit hospitals operating in states with high corporate taxes but low personal income taxes may face particular challenges of borrowing funds relative to their for-profit competitors.

Dr Egeland is senior director of business development and licensing in the Early Technologies business unit of the Minimally Invasive Therapies Group at Medtronic. Mr Rapp is an associate consultant at Pharmagellan, a biotech consultancy. Dr David is the founder and managing director of Pharmagellan.

Technological innovation in healthcare yields better health outcomes but also drives healthcare expenditure, and governments are struggling to maintain an appropriate balance between patient access to modern care and the economic sustainability of healthcare systems. Health Technology Assessment (HTA) and centralized procurement are increasingly used to govern the introduction and diffusion of new technologies in an effort to make access to innovation financially sustainable. However, little empirical evidence is available to determine how they affect the selection of new technologies and unit prices. This paper focuses on medical devices (MDs) and investigates the combined effect of various HTA governance models and procurement practices on the two steps of the MD purchasing process (i.e., selecting the product and setting the unit price). Our analyses are based on primary data collected through a national survey of Italian public hospitals. The Italian National Health Service is an ideal case study because it is highly decentralized and because regions have adopted different HTA governance models (i.e., regional, hospital-based, double-level or no HTA), often in combination with centralized regional procurement programs. Hence, the Italian case allows us to test the impact of different combinations of HTA models and procurement programs in the various regions. The results show that regional HTA increases the probability of purchasing the costliest devices, whereas hospital-based HTA functions more like a cost-containment unit. Centralized regional procurement does not significantly affect MD selection and is associated with a reduction in the MD unit price: on average, hospitals located in regions with centralized procurement pay 10.1% less for the same product. Hospitals located in regions with active regional HTA programs pay higher prices for the same device (+23.2% for inexpensive products), whereas hospitals that have developed internal HTA programs pay 8.3% on average more for the same product.

SURGEONS WILL INCREASINGLY BEAR FINANCIAL RISK WITH NEW PAYMENT MODELSValue-based reimbursement is supplanting traditional fee-for-service payment. Forward thinking payers, providers, and patients are redesigning care delivery to maximize patient experience and population-level health at an affordab

Objective To assess the impact of electronic health record (EHR) implementation on hospital finances. Materials and Methods We analyzed the impact of EHR implementation on bond ratings and net income from service to patients (NISP) at 32 hospitals that recently implemented a new EHR and a set of controls. Results After implementing an EHR, 7 hospitals had a bond downgrade, 7 had a bond upgrade, and 18 had no changes. There was no difference in the likelihood of bond rating changes or in changes to NISP following EHR go-live when compared to control hospitals. Discussion Most hospitals in our analysis saw no change in bond ratings following EHR go-live, with no significant differences observed between EHR implementation and control hospitals. There was also no apparent difference in NISP. Conclusions Implementation of an EHR did not appear to have an impact on bond ratings at the hospitals in our analysis.

Management improvement was strongly required at public hospital and Local Incorporated Administrative Agency hospitals in Japan. We analysed financial statements of 880 public hospitals using Business Intelligence System. In order to raise the efficiency of management, it is important to have patients with a high profitability (seriously ill patients) at municipal hospitals; whereas, in Local Incorporated Administrative Agency hospitals, avoiding producing ordinary losses and not incurring excessive expenses will be important for management improvement.

Background Over the past decade, many states have developed approaches to reimburse for immediate postpartum long-acting reversible contraception. Despite expanded coverage, few hospitals offer immediate postpartum long-acting reversible contraception. Objectives Immediate postpartum long-acting reversible contraception implementation is complex and requires a committed multidisciplinary team. After New Mexico Medicaid approved reimbursement for this service, the New Mexico Perinatal Collaborative developed and initiated an evidence-based implementation program containing several components. We sought to evaluate timing of the implementation process and facilitators and barriers to immediate postpartum long-acting reversible contraception in several New Mexico rural hospitals. The primary study outcome was time from New Mexico Perinatal Collaborative program component introduction in each hospital to the hospital’s completion of the corresponding implementation step. Secondary outcomes included barriers and facilitators to immediate postpartum contraception implementation. Study Design In this mixed-methods study, conducted from April 2017 to May 2018, we completed semistructured questionnaires and interviews with 20 key personnel from 7 New Mexico hospitals that planned to implement immediate postpartum long-acting reversible contraception. The New Mexico Perinatal Collaborative introduced program components to hospitals in a stepped-wedge design. Participants contributed baseline and follow-up data at 4 time periods detailing the steps taken towards program implementation and the timing of step completion at their hospital. Qualitative data were analyzed using directed qualitative content analysis principles based on the Consolidated Framework for Implementation Research. Results Investigators conducted 43 interviews during the 14-month study period. Median time to complete steps toward implementation—patient education, clinician training, nursing education, charge capture, available supplies, and protocols or guidelines—ranged from 7 days for clinician training to 357 days to develop patient education materials. Facilitators of immediate postpartum contraception readiness were local hospital clinical champions and institutional administrative and financial stability. Of the 7 hospitals, 4 completed all Perinatal Collaborative implementation program components and 3 of those piloted immediate postpartum long-acting reversible contraception services. Two publicly funded hospitals currently offer immediate postpartum long-acting reversible contraception without verification of payment for the device or insertion. The third hospital piloted the program with 8 contraceptive devices, did not receive reimbursement due to identified flaws in Medicaid billing guidance and does not currently offer the service. The remaining 3 of the 7 hospitals declined to complete the NMPC program; the hospital that completed the program but did not pilot immediate postpartum long-acting reversible contraception did so because Medicaid billing mechanisms were incompatible with their automated billing systems. Participants consistently reported that lack of reimbursement was the major barrier to immediate postpartum long-acting reversible contraception implementation. Conclusion Despite the New Mexico Perinatal Collaborative’s robust implementation process and hospital engagement, most hospitals did not offer immediate postpartum long-acting reversible contraception over the study period. Reimbursement obstacles prevented full service implementation. Interventions to improve immediate postpartum long-acting reversible contraception access must begin with implementation of seamless billing and reimbursement mechanisms to ensure adequate hospital payments.

Background Hospital medicine groups (HMGs) typically receive financial support from hospitals. Determining a fair amount of financial support requires negotiation between HMG and hospital leaders. As the hospital medicine care model evolves, hospital leaders may regularly challenge HMGs to demonstrate the financial value of activities that do not directly generate revenue. Objective To describe current attitudes and beliefs of hospital executives regarding the value of contributions made by HMGs. Design Thematic content analysis of key informant interviews. Participants Twenty-four healthcare institutional leaders, including hospital presidents, chief medical officers, chief executive officers, and chief financial officers. Participants comprised a diverse sample from all regions in the United States, including rural, suburban, and urban locations, and academic and nonacademic institutions. Results Executives highly valued hospitalist groups that demonstrate alignment with hospital priorities, and often used this concept to summarize the HMG's success across several value domains. Most executives evaluated only a few key HMG metrics, but almost no executives reported calculating the HMG return on investment by summing pertinent quantitative contributions. Respondents described an evolving concept of hospitalist value and believed that HMGs generate substantial value that is difficult to measure financially. Conclusions Hospital executives appear to make financial support decisions based on a small number of basic financial or care quality metrics combined with a subjective assessment of the HMG's broader alignment with hospital priorities. HMG leaders should focus on building relationships that facilitate dialog about alignment with hospital needs.

Background This paper aims to investigate the effects of corporate governance mechanisms on the financial performance of hospitals. The statement, "good corporate governance" has been incorporated in the health care sector over the last decade, as an element to improve financial performance. Methods The researchers relied on both primary and secondary data in the study. For the primary data, the authors used structured and nonstructured questionnaires to obtain data from 125 hospitals. The secondary data used emanated from board meetings, financial statements and relevant reports of the selected hospitals from 2010 to 2017. However, the data was then sorted out to get the required information on Chief Executive Officer (CEO) presence, board relationship, governance dynamics, gender diversity and financial performance. Results On the basis of empirical evidence provided in this study, the results show that the Independent Directors (INDPDR) variable has a positive effect on Return on Assets and Net Profit Margin and also a high statistically significant value of 0.000 for both performance measures. This is an indication that the variable, INDPDR, is highly capable of improving hospital financial performance. From our studies, Board Size and CEO Duality exhibited a negative relationship with the financial performance measures. Conclusions Every hospital needs money to maintain a standard health facility and to sustain in operation. However, the inclusion of board of directors improves hospital financial management and enhances performance. Corporate governance mechanisms influence the behavior of health systems in ways that are associated with financial performance.

Context As of March 23, 2012, the Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct Community Health Needs Assessment (CHNA) every 3 years to incentivize hospitals to provide programs responsive to the health needs of their communities. Objective To examine the distribution and variation in community benefit spending among North Carolina's tax-exempt hospitals 2 years after completing their first IRS-mandated CHNA. Design Cross-sectional study using secondary analysis of published community benefit reports. Community benefit was categorized on the basis of North Carolina Hospital Association's community benefit reporting guidelines. Multiple regression analysis using generalized linear model was used to examine the variation in community benefit spending among study hospitals considering differences in hospital-level and community characteristics. Setting Fifty-three private, nonprofit hospitals across North Carolina. Main outcome measure Dollar expenditures as a percentage of operating expenses of the 2 categories of community benefit spending: patient care financial assistance and community health programs. Results Study hospitals' aggregate community benefit spending was $2.6 billion, 85% of which was in the form of patient care financial assistance, with only 0.7% of total spending allocated to community-building activities such as affordable housing, economic development, and environmental improvements. On average, the study hospitals' community benefit spending was equivalent to 14.6% of operating expenses. Hospitals with 300 or more beds provided significantly higher investments in community health programs as a percentage of their operating expenses than hospitals with 101 to 299 beds (P = .03) or hospitals with 100 or fewer beds (P = .04). Access to care was not associated with patient care financial assistance (P = .81) or community health programs expenditures (P = .94). Conclusions The study hospitals direct most of their community benefit expenditures to patient care financial assistance (individual welfare) rather than population health improvement initiatives, with virtually no investments in community-building activities that address socioeconomic determinants of health.

This paper empirically investigates the impact of additional reimbursement instruments on the diffusion of new technologies in inpatient care. Using 2010-2014 German panel data on hospital level for every patient undergoing coronary angioplasty, this study examines the utilisation of drug-eluting balloon catheters (DEB) over time while additional payment instruments changed. Hypothesising that the utilisation of DEB increased abruptly when a new reimbursement instrument came into force, we estimate a fixed effects regression comparing years with a change and years where the reimbursement instrument remained the same. The model is adjusted for patient age and severity of the disease. The utilisation of DEB increased from 8407 in 2010 to 19,065 in 2014. Hospitals used significantly more DEB when an additional payment instrument changed compared to years when it remained the same. The increase was roughly twice as large. In short, hospitals are incentivised to utilise new technologies if the reimbursement changes to an instrument that is designed in a more reliable way, e.g. including less bureaucracy or guaranteeing fixed prices.