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Journal of Business Ethics

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13.12.2017 | Original Paper

Does State Community Benefits Regulation Influence Charity Care and Operational Efficiency in U.S. Non-profit Hospitals?

verfasst von: Melvin A. Lamboy-Ruiz, James N. Cannon, Olena V. Watanabe

Erschienen in: Journal of Business Ethics | Ausgabe 2/2019

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Abstract

Using a comprehensive sample of U.S. non-profit hospitals from 2011 to 2015, we examine the effects of state community benefits regulation (CBR) on the amount of charity care provided by and the operational efficiency of U.S. non-profit hospitals. First, we document that, under such regulations, non-profit hospitals provide more charity care and less compensated care as a proportion of net revenue. We infer from these findings that CBR has the potential to increase both non-profit hospitals’ amount of charity care and their efficiency of operations. Second, by examining variation in CBR types, we find no differences between having provision or having reporting requirements on the amount of charity care offered. Moreover, when we consider CBR with both provision and reporting requirements, the combination of these two requirements does not incrementally enhance charity care offerings, suggesting that the requirements may serve as substitutes with comparable effect. Lastly, we show that several state-level characteristics influence the relationship between CBR and charity care: CBRs in states with a higher gross domestic product and percentage of revenue received in taxes have incrementally lower associations with charity care, while hospitals in states where populations have, on average, higher household incomes have greater associations between CBR and charity care. Our findings highlight the effects that state-enacted regulation can have on socially beneficial behavior by non-profits.

Vorheriger Artikel Ethical Leadership and Corporate Social Responsibility in China: A Multilevel Study of Their Effects on Trust and Organizational Citizenship Behavior

Nächster Artikel Managerial Efficiency, Corporate Social Performance, and Corporate Financial Performance

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Specifically, over the period from 2007 to 2012, non-profit employment increased by 8.5%, from 10.5 to 11.4 million jobs in the U.S. Over that same period, the number of non-profit organizations increased by 15% (Friesenhahn 2016). The non-profit healthcare sector provides 57% of non-profit jobs (Lambert 2013).

The Henry J. Kaiser Family Foundation reported that more than 72 million (~ 23% of the population) Americans were without health insurance coverage or federal care benefits coverage in 2013, and that these individuals incurred an average of $2443 in annual health care costs (Coughlin et al. 2014).

The U.S. Government Accountability Office (2008) describes community benefits as the provision of charity care, health education, and screening services to specific vulnerable populations within a community, as well as activities that benefit the greater public good, such as education for medical professionals and medical research. Charity care is a cost of medical services provided free of charge or at discounted prices to patients. A hospital typically reports on its earnings statement an item called “uncompensated care,” which encompasses all community benefits provided. To vary the exposition, we use the terms “uncompensated care,” “charity care,” and “community benefits” interchangeably.

Non-profit hospitals, as with all other non-profits, cannot distribute residual income to internal or external stakeholders (Eldenburg et al. 2015). Non-profits can reinvest earnings into new projects/expansions, offer more charity care, or accumulate earnings in an “unrestricted net position,” an equivalent to retained earnings in a for-profit organization.

As of 2010, non-profit hospitals also need to comply with expanded requirements, added under the Affordable Care Act, such as limitations on the charges for emergency and necessary medical care services for individuals who qualify under hospital medical assistance programs (https://www.irs.gov/Charities-&-Non-profits/Charitable-Organizations/New-Requirements-for-501(c)(3)-Hospitals-Under-the-Affordable-Care-Act).

In some cases, local governments perceived the under-provision of public benefits to be sufficiently significant to revoke a hospital’s non-profit status. Such revocations have been upheld in the state court system. For instance, in 2008 the Illinois Fourth District Court of Appeals ruled in Provena Covenant Medical Center v. the Department of Revenue (2010) that Provena Covenant Medical Center did not provide enough charity care in 2002 to merit $1.1 million in property tax exemption. The ruling by the appellate court was upheld on March 18, 2010, by the Illinois Supreme Court (http://www.illinoiscourts.gov/opinions/supremecourt/2010/march/107328.pdf).

In fact, there is some evidence that non-profit managers’ compensation can be based on measures that reduce earnings (Preyra and Pink 2001).

At the federal level, effective 2008, the Internal Revenue Service (IRS) added “Schedule H: Hospitals” to Form 990. Schedule H requires non-profit hospitals to disclose standardized information about community benefits. Its purpose was “to promote transparency and compliance… to develop risk models to assess the likelihood of noncompliance by organizations, allowing more effective use of examination resources” (IRS 2012). We expect the enhanced IRS oversight, effective 2008, to result in greater compliance (i.e., community benefit provision) across all federally tax-exempt hospitals across all states. It is possible that the enhanced oversight offered by Form 990, Schedule H would subsume any regulatory effects of state-level CBR, offering a plausible null hypothesis for our study. Further, non-profit status, although often associated with federal tax-exempt status, is a distinct state-level concept. That is, only states may revoke a hospital’s non-profit status (and the accompanying state-level tax benefits), whereas the IRS can only revoke federal tax-exempt status (IRS 2017). Thus, because each level of government has its own jurisdiction, we expect that state CBR offers an incremental level of governance to that offered at the federal level.

Bad debt expense includes only non-Medicare bad debt costs and non-reimbursable Medicare bad debt costs (MCR Worksheet S-10, line 29).

In hospital accounting systems, all patient services provided are recorded at gross charges (gross patient care revenue). When a patient is approved for charity care, the hospital writes off those changes via contractual allowance. On MCR Worksheet S-10, charity care and bad debt expense are calculated by multiplying charity care and bad debt charges by the cost-to-charge ratio (CCR). To alleviate the concerns that managers over-report charity care by inflating uncompensated care charges, we control for variation in CCRs across hospitals in our empirical model.

Existing literature differs in the approaches used to measure and scale charity care costs. Vansant (2015) uses gross charity care charges and scales them by total assets; Eldenburg et al. (2004) and Bai (2013) scale the metric of uncompensated care charges by gross patient revenues. Both Vansant (2015) and Eldenburg et al. (2004) rely on California’s Office of Statewide Health Planning and Development for charity care data. This office does not report charity care costs separately from other expenses, but it does report charity care at gross charges as a deduction from gross revenue (also reported at charges and including charity care); therefore, in Vansant’s (2015) study, the effect of charity care on net revenue is zero. We use MCRs, which allow us to obtain uncompensated care costs. However, in robustness tests we re-estimate our models using total assets as an alternative scalar of uncompensated care costs.

Medicaid costs, State Children’s Health Insurance Program costs (focused on medically indigent children), and other state and local indigent healthcare program costs are not included in our definition of community benefit costs because these programs are intended to compensate hospitals with a program amount for providing healthcare services to program beneficiaries. In cases where the hospital does not receive reimbursement for such patients, the hospital absorbs the cost. Since some states do not include such unreimbursed costs in their definition of community benefits, for consistency we opt to exclude them from our measurement of the costs of community benefits in all states.

For clarification, we note that our measure of compensated care costs not only includes costs recovered through patients and third-party payers, but it also includes care costs labeled “uncompensated” that are covered by private grants (MCR Worksheet S-10, line 17) and those covered by government appropriations (MCR Worksheet S-10, line 18).

Note that no states in our sample experience enacted community benefits laws during the sample period. Therefore, we avoid transitional periods and examine all hospitals under a stable CBR regime.

To address concerns that there is overlap between the constructs of individual household income (median household income) and state-level income (GDP), we examine bivariate correlation and test for multicollinearity in our regression analysis. We find that Log_Med_Hshld_Income_t has a modest pairwise (Pearson) correlation of 0.22 with LogGDP_t. In the regressions, the largest variance inflation factor is 2.7. Finally, the signs and significance of those coefficients on Log_Med_Hshld_Income_t and LogGDP_t are unchanged when we systematically remove each variable. Thus, we conclude our variables are capturing largely different constructs.

We obtained the latest update of the data used in this study from the CMS database on December 31, 2016. MCRs are posted with a significant delay; therefore, without complete data available for 2016, we end our sample in 2015.

According to the Hilltop Institute, these states are Illinois, Nevada, Pennsylvania, Texas, and Utah.

In untabulated analysis, we substitute the logarithmic transformation of total assets instead of Beds_t. The positive association between CBR and charity care remains robust.

As an untabulated robustness test, we adjust Log_Med_Hshld_Income_t and LogGDP_t for inflation, using 2011 as our base year and the Consumer Price Index reported by U.S. Bureau of Labor Statistics (https://www.bls.gov/cpi/data.htm). The results are materially indistinguishable from those reported in the primary results.

We recognize that our setting does not allow for a model with state-level fixed effects. However, in further untabulated analysis, we employ a Hausman and Taylor (1981) two-stage least squares model to mitigate concerns about time-invariant state-level omitted correlated variables. We calculate and use as an exogenous time-invariant instrument the mean proportion of for-profit hospitals by state and across sampled years. The results of the Hausman-Taylor approach are consistent with our primary results, offering further confidence that our primary results are not biased by endogeneity. We thank an anonymous reviewer for this suggestion.

In Table 6, our dependent variable is UCC_t. We perform all applicable robustness tests using CCC_t as a dependent variable as well, but we do not report them for parsimony. Our inferences remain unchanged with respect to the association of CBR with compensated care costs as a proportion of net revenue.

Not all hospitals in our sample report bad debt expense. Although, for our main tests, we assume bad debt expense is equal to zero if unreported, for robustness tests we eliminate hospital-years where bad debt expense is missing, resulting in a maximum sample size of 6616 hospital-years.

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Titel: Does State Community Benefits Regulation Influence Charity Care and Operational Efficiency in U.S. Non-profit Hospitals?
verfasst von: Melvin A. Lamboy-Ruiz
James N. Cannon
Olena V. Watanabe
Publikationsdatum: 13.12.2017
Verlag: Springer Netherlands
Erschienen in: Journal of Business Ethics / Ausgabe 2/2019
Print ISSN: 0167-4544
Elektronische ISSN: 1573-0697
DOI: https://doi.org/10.1007/s10551-017-3757-2

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