Journal of Healthcare Management最新文献

Goal: This study aimed to compare the value of tax exemptions and community benefits across various nonprofit hospitals and show how hospital and geographical characteristics can explain the values.

Methods: Data from 2017 to 2021 Internal Revenue Service Form 990s were used to evaluate 17 types of community benefits in nonprofit hospitals and assess six categories of tax benefits. Descriptive analyses compared charity care, community benefits, and estimated tax exemptions among nonprofit hospitals while considering variations in teaching status, location (rurality), and US region. Additionally, random effect regression analyses, both unadjusted and adjusted, explored the connection between the community benefit-to-expense ratio and a range of hospital and geographical features.

Principal findings: Between 2017 and 2021, nonprofit hospitals allocated, on average, 8.8% of their total expenses to 17 types of community benefits, with 1.8% of their expenses dedicated to charity care; 5.2% benefited from tax exemptions. There were significant disparities among nonprofit hospitals, as 24.0% received more tax benefits than they spent on community benefits, and 81.0% received more than their charity care expenditures. The characteristics and location of nonprofit hospitals influenced the provision and composition of community benefits. Teaching hospitals allocated a higher percentage of total community benefits compared to nonteaching hospitals (9.2% vs. 8.6%). The top three categories in teaching hospitals were Medicaid shortfall, charity care, and unreimbursed education, whereas nonteaching hospitals focused more on charity care and subsidized health services, in addition to Medicaid shortfall. Furthermore, the location of a nonprofit hospital impacted the distribution of community benefits. Rural hospitals prioritized Medicaid shortfall, subsidized health services, and charity care, while urban hospitals concentrated more on Medicaid shortfall, charity care, and subsidized health service (in that order). The regression results showed that system affiliation and location in the Southern region of the United States were positive predictors of charity care spending at nonprofits.

Practical applications: Lack of transparency and explicit requirements from federal agencies and states for what is necessary to receive tax benefits results in wide variations in community benefits spending by nonprofit hospitals. Some receive more in tax benefits than they provide in community benefits, and three-quarters of all nonprofit hospitals receive more in tax benefits than they provide in charity care. Developing a more explicit definition of community benefits can make all nonprofit hospitals more accountable.

Goal: This research aimed to evaluate variations in perceived organizational support among physicians during the first year of the COVID-19 pandemic and the associations between perceived organizational support, physician burnout, and professional fulfillment.

Methods: Between November 20, 2020, and March 23, 2021, 1,162 of 3,671 physicians (31.7%) responded to the study survey by mail, and 6,348 of 90,000 (7.1%) responded to an online version. Burnout was assessed using the Maslach Burnout Inventory, and perceived organizational support was assessed by questions developed and previously tested by the Stanford Medicine WellMD Center. Professional fulfillment was measured using the Stanford Professional Fulfillment Index.

Principal findings: Responses to organizational support questions were received from 5,933 physicians. The mean organizational support score (OSS) for male physicians was higher than the mean OSS for female physicians (5.99 vs. 5.41, respectively, on a 0-10 scale, higher score favorable; p < .001). On multivariable analysis controlling for demographic and professional factors, female physicians (odds ratio [OR] 0.66; 95% CI: 0.55-0.78) and physicians with children under 18 years of age (OR 0.72; 95% CI: 0.56-0.91) had lower odds of an OSS in the top quartile (i.e., a high OSS score). Specialty was also associated with perceived OSS in mean-variance analysis, with some specialties (e.g., pathology and dermatology) more likely to perceive significant organizational support relative to the reference specialty (i.e., internal medicine subspecialty) and others (e.g., anesthesiology and emergency medicine) less likely to perceive support. Physicians who worked more hours per week (OR for each additional hour/week 0.99; 95% CI: 0.99-1.00) were less likely to have an OSS in the top quartile. On multivariable analysis, adjusting for personal and professional factors, each one-point increase in OSS was associated with 21% lower odds of burnout (OR 0.79; 95% CI: 0.77-0.81) and 32% higher odds of professional fulfillment (OR 1.32; 95% CI: 1.28-1.36).

Practical applications: Perceived organizational support of physicians during the COVID-19 pandemic was associated with a lower risk of burnout and a higher likelihood of professional fulfillment. Women physicians, physicians with children under 18 years of age, physicians in certain specialties, and physicians working more hours reported lower perceived organizational support. These gaps must be addressed in conjunction with broad efforts to improve organizational support.

Goal: Recent efforts to push hospitals to provide high-value care have relied on payment incentives. However, evidence indicates that 70% to 90% of performance improvement projects do not achieve their desired goals. Therefore, in addition to managing external industry pressures, hospitals need to develop performance improvement (PI) capabilities that enable them to capitalize on improvement opportunities, effectively develop and adopt solutions, and ensure the sustainability of improvements over time. While operational capabilities enable hospitals to produce and deliver services, more is needed to attain and sustain superior performance. Dynamic capabilities drive changes in operational capabilities to meet environmental demands. Dynamic capabilities also enable hospitals to renew and reconfigure their resources to optimize performance. This paper proposes the dynamic-capabilities framework as an appropriate way to develop and manage PI capabilities in hospitals, and it discusses the implications of shifting to a strategy that is driven by dynamic-capabilities PI.

Methods: The research team designed a semi-structured interview based on a review of the literature to understand whether hospitals were engaging in the activities outlined in the dynamic-capabilities framework. Nine study participants were recruited from a convenience sample of hospital PI staff at hospitals in Massachusetts and New Hampshire. De-identified transcripts were entered into NVivo12 qualitative data analysis software, and data were thematically indexed and coded following the principles of content analysis.

Principal findings: PI structures, improvement methodologies, and weaknesses did not vary significantly among hospitals. Most hospitals had a PI department and were more likely to adopt PI projects initiated by top management. While PI staff were trained in improvement methodologies, no programs were in place that required the rest of the hospital staff to become familiar with PI methods. Common areas of weakness were PI project selection, communication, coordination, learning from current and former PI projects, and systematic approaches to sustain improvements.

Practical applications: Dynamic PI capabilities provide an opportunity to systematically identify improvement opportunities, seize on and learn from those opportunities, and renew and reconfigure resources to optimize performance. Ad hoc PI projects are insufficient to enable a hospital to sustain superior performance. Internal and external pressures to deliver high-value patient care and services require hospitals to exceed their current PI efforts. By developing dynamic PI capabilities, hospitals will adopt a more systematic and effective approach to PI, which will likely result in superior performance.

Goal: To document shifts in rural hospital service line offerings between 2010 and 2021 and to assess the resulting impacts on hospital profitability.

Methods: We used annual Medicare cost report data for all rural hospitals that did not change payment classifications between 2010 and 2021. We documented changes in the percentages of hospitals offering each of the 37 inpatient or ancillary service lines included in the data. We then used panel event studies to assess effects on hospital operating margin for specific service lines that changed most prominently during this period.

Principal findings: Twelve service lines changed by more than 5% during our period of analysis. These are highlighted by hospitals adding rural health clinics (+32%) and CT scans (+20%) and removing delivery rooms (-21%) and skilled nursing facilities (-19%). Panel event studies demonstrated that the addition or subtraction of most services did not have statistically significant impacts on future hospital operating margins. Notable exceptions were the addition of rural health clinics and the removal of delivery services, both of which positively affected future operating margins. The addition of occupational therapy services had a positive effect on operating margin in the near term, but adding MRI services had a negative effect.

Practical applications: The finding that only a select few service line changes resulted in meaningful impacts to hospital operating margins suggests that hospital leaders should be wary of implementing such changes as a means of improving financial viability.