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The federal Employee Retirement Income Security Act of 1974 (ERISA) supersedes state laws as they relate to employer-based health care plans. Thus, cases brought under ERISA are heard in federal courts.

Legislatures have made numerous attempts to reduce medical malpractice costs by changing the legal rules governing malpractice suits. Additional changes through physician discipline are also under consideration. This paper ‐ tests whether these changes have had the desired effects, using cross‐state data. The empirical findings are that the results of changes in the legal rules are generally as expected, but that physician discipline seems to have little impact on either insurer costs or insurance rates, even after the discipline rules have been in effect for up to four years.

Several studies have shown that Medicaid expansion has improved hospital financial performance. All of these studies have either used data from the Internal Revenue Service (IRS) or the Centers for Medicare and Medicaid Services (CMS), and none of them has examined the state-level impact of expansion on hospital finances. Using data for not-for-profit hospitals from both IRS and CMS for 2011-2016, we described the difference in costs related to uncompensated care and Medicaid shortfalls. We then estimated the impact of Medicaid expansion on hospitals' financial status nationally and by state. Nationally, the estimated net effect of expansion reduced not-for-profit hospital costs by 2 percentage points based on IRS data and 0.83 percentage points based on CMS data. Across expansion states, the estimated net effects varied widely with approximately a 10-fold difference for hospitals based on IRS data and a 2-fold difference based on CMS data. Future studies should further explore the differences across IRS and CMS data.

ABSTRACTA dramatic change in the hospital industry is the increasing emphasis on linking provider payment to quality performance metrics. This is one of several considerations leading hospitals to employ physicians. Yet, there is little evidence regarding whether physician employment as a form of hospital‐physician integration leads to better operational performance. Using data from 201 California hospitals that experienced a total of 405,766 eligible opportunities to conform to external performance metrics (conformance quality) for treating patients in the cardiovascular service area, we empirically evaluated the relationship between physician employment and conformance quality. We also evaluated whether the presence of core capabilities in the hospital's cardiovascular service area complements or substitutes for physician employment. Findings suggest that physician employment is not only positively associated with conformance quality, but also associated with more consistent conformance quality. Moreover, the presence of core capabilities in the service area substitutes for physician employment. Theoretical, managerial, and policy implications are discussed.

The recent growth of physician‐owned hospitals specializing in orthopedic and surgical specialty services in the United States has generated considerable controversy, yet there is little understanding of the economic logic of organizing hospital services around these single specialties. This article takes a multiple output hospital cost function approach to an empirical investigation of whether single specialty hospitals (SSHs) exhibit economies of scale and economies of scope as keys to new insights into that logic. We applied generalized estimating equation techniques to a sample of 80SSHsand 883 general hospital competitors over the 1998–2008 period. Results indicated large underlying scale differences across the organizational types. Simulation analysis revealed the potential for exploitation of economies of scope gained from shifting output fromSSHsto general hospitals. (JELI18, L23)

Advocates of physician-owned single specialty hospitals (SSHs) maintain that, through healthy competition, SSHs pressure competitor hospitals in local markets to improve performance. This paper investigates data trends on the effects of SSH entry on a potential indicator of quality of care in general hospital competitors: nurse staffing levels. We examined registered nurse (RN) staffing from 1997 to 2004 in ten states in which there was considerable SSH entry during this period. Regression estimates used longitudinal panel data models with hospital fixed effects to compare changes in numbers of RNs in general hospitals located in markets with SSHs with general hospitals located in markets where there were no SSHs. Results indicate that hospitals located in markets with orthopedic/surgical SSH presence raised their RN nurse staffing levels. Whether or not these changes are associated with improved patient outcomes is unknown.

The authors examined, on a case-by-case basis, the community impact of 15 for-profit hospitals that converted to nonprofit status. These for-profit conversions have been occurring in numbers comparable with those of nonprofit conversions (i.e., nonprofit hospitals that convert to for-profit status), but have attracted far less attention. For each for-profit conversion, the authors compared the change in uncompensated care with the loss to the local community in property tax revenue. In 11 of the 15 cases, the conversion was followed by some level of increase in uncompensated care. However, only three of these conversions produced enough additional uncompensated care to offset the loss in property tax revenue to the community. This analysis, while only a starting point for addressing the community impact of for-profit conversions, suggests that for-profit conversions do not uniformly promote the welfare of the communities where they occur.

CONTEXT: Achieving meaningful population health improvements has become a priority for communities across the United States, yet funding to sustain multisector initiatives is frequently not available. One potential source of funding for population health initiatives is the community benefit expenditures that are required of nonprofit hospitals to maintain their tax-exempt status. OBJECTIVE: In this article, we explore the importance of nonprofit hospitals' community benefit dollars as a funding source for population health. DESIGN: Hospitals' community benefit expenditures were obtained from their 2009 IRS (Internal Revenue Service) Form 990 Schedule H and complemented with data on state and local public health spending from the Association of State and Territorial Health Officials and the National Association of County & City Health Officials. Key measures included indicators of hospitals' community health spending and governmental public health spending, all aggregated to the state level. Univariate and bivariate statistics were used to describe how much hospitals spent on programs and activities for the community at large and to understand the relationship between hospitals' spending and the expenditures of state and local health departments. RESULTS: Tax-exempt hospitals spent a median of $130 per capita on community benefit activities, of which almost $11 went toward community health improvement and community-building activities. In comparison, median state and local health department spending amounted to $82 and $48 per capita, respectively. Hospitals' spending thus contributed an additional 9% to the resources available for population health to state and local health departments. Spending, however, varied widely by state and was unrelated to governmental public health spending. Moreover, adding hospitals' spending to the financial resources available to governmental public health agencies did not reduce existing inequalities in population health funding across states. CONCLUSIONS: Hospitals' community ...

Gender pay equity is a desirable social value and an important strategy to fill every organizational stratum with gender-diverse talent to fulfill an organization's goals and mission. This study used national, large-sample data to examine gender difference in CEO compensation among not-for-profit hospitals. Results showed the average unadjusted annual compensation for female CEOs in 2009 was $425,085 compared with $581,121 for male CEOs. With few exceptions, the difference existed across all types of not-for-profit hospitals. After controlling for hospital- and area-level characteristics, female CEOs of not-for-profit hospitals earned 22.6% less than male CEOs of not-for-profit hospitals. This translates into an earnings differential of $132,652 associated with gender. Explanations and implications of the results are discussed.

In a cross-sectional observational study of Rochester (New York) primary care physicians (PCPs) enrolled in a pay-for-performance (P4P) collaboration, the authors investigated attitudinal factors associated with provider adherence to evidence-based clinical guidelines targeted by explicit incentives. The multivariable adherence model linked guideline adherence rates to provider attitudes among 186 survey respondents, adjusting for individual, practice, and community characteristics. Adherence was defined as the percentage of expected services that were delivered. Attitudes associated with adherence, independent of specialty and prior behavior, were financial salience (adjusted odds ratio [OR] = 3.6; 95% confidence interval [CI] = 1.7-8.4), peer cooperation (OR = 2.0; 95% CI = 1.0-4.0), control (OR = 0.5; 95% CI = 0.3-1.0), and autonomy regarding the health plan (OR = 0.3; 95% CI = 0.1-0.6). The most adherent providers perceived P4P as financially salient and felt supported by peers. Some PCPs might have perceived P4P and external interventions as challenging their autonomy and "crowding out" their intrinsic motivation, leading them to reduce efforts aimed at guideline adherence.

Pay-for-quality (P4Q) initiatives are becoming an increasingly popular mechanism for improving quality performance and reducing health care costs in the United States. Because these programs often target primary care physicians, it is important to understand how these physicians perceive and respond to P4Q to design successful programs going forward. This study reports results of a survey regarding attitudes toward P4Q among physicians participating in such programs in Massachusetts and California. Findings indicate physicians have generally positive attitudes toward the concept of P4Q, but are ambivalent about certain features of these programs as currently designed and implemented.