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For-Profit Enterprise in Health Care. 1986. National Academy Press, Washington, D.C. Hospital Ownership and Comparative Hospice Costs Craig G. Coelen INTRODUCTION Proprietary hospitals have become increas- ingly common in the United States in the past decade, and this trend has provoked a debate about the relative cost of patient care in pro- pnetary versus nonprofit hospitals. Of partic- ular concern have been the implications of the growth of proprietary chains, through con- struction and acquisition. Advocates of pro- prietary ownership point to the advantages of economies of scale and the profit-related in- centive for efficiency. Detractors raise con- cerns about high costs of capital, high charge/ cost ratios, and limitations on access for charity cases and Medicaid beneficiaries. Previous empirical studies of comparative costs among different types of hospitals do not provide uniform conclusions. Ermann and Ga- be} (1986) review a dozen studies and conclude that "the consensus . . . is that [proprietary and nonprofit chains] increase the cost of care frelative to independent hospitals]. The con- clusion holds whether costs are measured as hospital expenses, revenues, or charges, on a per admission or per diem basis." Because half of the studies indicate that proprietary hos- pitals and/or proprietary chains are less ex- pensive or, at worst, no more expensive than nonprofit hospitals, it is our view that there is no consensus in the existing evidence. The 12 studies reviewed by Ermann and Gabel diner widely with respect to measures of cost, research samples, analytic techniques, and controls for possible differences in case max. Most studies compare costs among hos- pitals in only one or a few states and warn readers about the danger of generalizing their Dr. Coelen is with Abt Associates, Inc., Cambridge, Massachusetts. 322 results to other areas. In most cases, the sam- ple sizes are so small that multivariate statis- tical techniques cannot be used to account for the influence of cost determinants other than ownership. Because case mix is not accounted for explicitly in any of the studies, the reader is left with conclusions of the form: "Unless the patients admitted to proprietary hospitals are sicker (less sick) than those admitted to nonprofit hospitals, proprietary hospitals are more expensive (less expensive) than similar nonprofit institutions." Reexamining the relationship between hos- pital ownership and the cost of hospital care, we hope to improve upon earlier research in several ways. First, we use data for a gener- alizable sample of community hospitals in the 48 contiguous states and the District of Co- lumbia. Second, by presenting the dispersion of cost per patient among hospitals within each group and then comparing the distributions across groups, we are able to assess the relative homogeneity of different groups. Third, by ex- plicitly adjusting for cross-sectional differences in case mix in our analysis, we are able to limit the degree to which we must qualif y our con- clusions about comparative costs. We confine our discussion of interhospital differences to the following set of indicators of hospital performance: Level and annual rate of change of ex- pense per discharge Average length of stay Level and annual rate of change of num- ber of discharges Total, routine, and ancillary charges per discharge and Margins on patient revenue and total rev- enue. Although we do not provide detailed statis- tical results, we have examined other indica

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HOSPITAL OWNERSHIP AND COMPARATIVE COSTS tors during our analysis and will refer to the findings as relevant. DATA Data are drawn from information compiled for a large evaluation of hospital prospective reimbursement programs for the Health Care Financing Administration (HCFA). The prin- cipal facts about our data are the following: Measures of hospital expense, utilization, and margins are drawn from hospitals' Medi- care cost reports, although information from American Hospital Association (AMA) annual surveys has been used extensively to test for errors in coding and keypunching. Measures of total, routine, and ancillary charges per discharge are drawn from a 20 percent sample of Medicare patients with se- lected medical problems.2 Comparing total charges per patient from this source with hos- pital-wide average charges per patient from cost reports, we find that Medicare-only charges accurately reflect differences in gross patient service revenue across groups of hospitals. ~ Hospital expense has been divided by a uniquely derived measure of adjusted dis- charges. The adjustment for outpatient ser- vices and inpatient days in skilled nursing facility (SNF) units is accomplished by regressing the annual rate of change of expense on annual rates of change of acute care discharges, length of stay, SNF days per acute care discharge, outpatient visits per acute care discharges, and a variety of variables measuring the charac- teristics of hospital catchment areas. Regres- sion coefficients from this short-term cost function are then used to convert SNF days and outpatient visits to equivalent values of acute care discharges. RESEARCH SAMPLE Unlilce the samples used in most other stud- ies of comparative hospital costs, our sample is representative of the 48 contiguous states and the District of Columbia. The sample was selected as follows: ~ A 25 percent simple random sample of community hospitals was selected. Specialty hospitals, those run by federal or state agen 323 cies, and those with median values of average length of stay from 1969 to 1981 in excess of 15 days were excluded. ~ All remaining eligible hospitals in He 15 states with prospective reimbursement pro- grams of interest to HCFA were added to the proportional sample. The states were Arizona, Colorado, Connecticut, Indiana, Kentucky, Maryland, Massachusetts, Minnesota, Ne- braska, New Jersey, New York, Pennsylvania, Rhode Island, Washington, and Wisconsin. For this study, hospitals run by local gov- ernment agencies and hospitads with mem- bership in the Council of Teaching Hospitals were excluded. For analyses of hospital expense, utili- zation rates, and charges, data are available for each year from 1975 to 1981. The analyses of hospital margins are based on data from 1975 to 1979. Table 1 displays sample size by type of hos- pital and year. Because the sample over-rep- resents states with prospective reimbursement programs (primarily in the northeast), all ma- jor analyses have been redone for a strictly proportional sample. Because findings about comparative cost across types of hospitals did not change when the proportional sample was used, only results for the complete sample are reported here. ANALYTIC METHODS lbe method used to estimate costs, charges, utilization rates, and margins among groups of hospitals is multiple regression analysis. This technique computes intergroup differences that are adjusted for geographic location, catch- ment area charactenstics, presence/absence of regulatory programs (prospective reimburse- ment, certificate-of-need programs, and bind- ing professional standards review organization review [PSRO]), bed size, and case mix. Once the influence of these other potential deter- minants of hospital behavior has been taken into account, residual~ifferences among groups of hospitals can be reliably attributed to dif- ferences in management. Table A. 1 in the appendix provides a list of all dependent and explanatory variables in- cluded in multiple regression models and pre

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324 FOR-PROFIT ENTER[R1SE IN HEALTH CARE TABLE 1 Sample Size by Type of Hospital and Yeara Proprietary Hospitals Nonprofit Hospitals _ All Four Year Chain Independent Chain Independent Types _ 975 92 188 419 1,083 1,782 976 96 170 419 1,073 1,758 977 100 157 424 1,065 1,746 978 100 141 424 1,046 1,711 979 104 132 423 1,020 1,679 980 108 128 424 1,004 1,664 981 108 129 418 982 1,637 ache sample excludes hospitals that opened after 1977; sample size by 1981 is lower by about 60 hospitals third would otherwise be the case. The sample size decreases over time as the result of hospital closures. sents means and standard deviations for the set of observations used in analyses. The ex planatory variables are Six dummy variables for the year to which data apply; these constitute a more flexible specification of secular influences than a sim ple linear time trend (dummy variable for 1975 is omitted). Three dummy variables for type of own ership; since a dummy variable for indepen dent (nonchain) nonprofit hospitals is omitted, all three coefficients for ownership variables measure differences with respect to this omit ted, and most common, category of hospital. The logarithm of the hospital's Medicare case-mix index for 1982, propagated to all other years, as a rough measure of differences in case RESULTS type across hospitals (but not across years). Four dummy variables representing ur ban, nonurban, and regional location of hos pitals; Three dummy variables indicating pres encelabsence of regulatory programs for each hospital year prospective reimbursement, binding PSRO utilization review, and certifi cate of need; and ~ Sixteen continuous variables to control for relevant characteristics of the catchment areas (counties) served by each hospital socioeco nomic characteristics of the population, eco nomic conditions, insurance coverage, and availability of physicians and nursing home beds. For selected measures of hospital perfor mance we present comparative histograms to indicate differences in distributions across the four groups of hospitals. Although multiple regression analyses provide estimates of dif- ferences in adjusted means and indicate the statistical significance of Hose differences, they Lo not provide an adequate indication of dis- persion within a group and relative dispersion across groups. Ibe comparative histograms complement the results of regression analyses by indicating the degree to which statistically significant differences in means are typical of most hospitals or are the result of large dif- ferences between a minority of hospitals in each group (so called outliers). Table 2 presents estimated differences across the four groups of hospitals for 10 indicators of performance. These estimates, derived from multiple regression analyses reported in the appendix, are adjusted for differences in lo- cation, catchment area characteristics, pres- ence/absence of regulatory programs directed at hospitals, bed size and case mix. Figure 1, comparing the dispersion of case mix among hospitals across the four groups, illustrates the degree to which these potential determinants of hospital behavior vary across We four groups. Proprietary chain hospitals, for example, are concentrated primarily in southern and west- ern states, whereas other types of hospitals are more equally distributed geographically. In- dependent proprietary hospitals tend to have

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HOSPITAL OWNERSHIP AND COMPARATIVE COSTS TABLE 2 Estimated Differences in Cost, Utilization, Charges, and Margins Among Hospitals: Summary of Results from Regression Analyses Difference Relative to Independent Nonprofit Hospitals 325 Proprietary Proprietary Nonprofit Performance Measurea Chains Independents Chains Total expense per adjusted discharge (% difference) s.8b- 4.2b1.gb Annual rate of change of expense per case (percentage point difference in rate of growth) -0.4- 1.2b-0.2 Average length of stay (% difference) 0.22.2b1.3b Number of discharges (% difference) - 7. 7b-2. 32. 2b Annual rate of change of number of discharges (percentage point difference in rate of growth l.ob0.3o.5b Medicare charges/case (% difference) 1g.obll.2b3.5b Medicare routine charges/ case (% difference) -1.27.4b2.2b Ancillary charges per case (% difference) 33 gb14.5b5.1b Margin on patient revenue (percentage point difFerence) 5.5b3.3b- o.6b Margin on total revenue (percentage point difFerence) 1.8bl.lb-o.6b CEstimates in each of the 10 rows of the table are derived from Appendix tables A.2 through A. 11. All measures except Medicare charges per case apply to the entire hospital and all patients. b probability that measured differences are due to chance is less ~an 5 percent. fewer beds than other types of hospitals and a higher frequency of low-intensity case mix. Only those differences in performance indi- cators across groups that are not associated with differences, location, case mix, and other factors are re~ected in our measures of di~er- ences due to ownership. Experience per Discharge Total hospital expense per adjusted dis- charge varies by as much as 10 percent among the average hospitals in each ofthe four groups, or by as much as $250 per case in 1981 dolIars.2 Independent hospitals are less expensive than chainmperated hospitals, and a~nong indepen- dent institutions, proprietary hospitals are percent less expensive than nonprofit hospi- tals. Nonprofit chains are 2 percent more ex- pensive, on average, than independent nonprofit institutions. Proprietary chains are the most expensive of all four groups 6 per- cent more costly than nonprofit independents and 10 percent more expensive than proprie- tary independents. Our results clearly dispute the presumed advantages of chain-operated hospitals in general, and proprietary chains in

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326 FOR-PROFIT ENTERPRISE IN HEALTH CARE 40 en 0 30 o At mu C: 20 10 o ~ Proprietary Chains _ . Proprietary Independents Non-Profit Chains Non-Profit Independents it - Be_ _ <90 90-95 95-1 00 _ , , 100-105 105-110 >110 PERCENT OF NATIONAL AVERAGE E]GURE 1 Comparative dispersion of Medicare case-mix index (year 1980~. particular, from economies of scale and profit- related incentives for minimization of cost.3 In addition to providing care at the most economical cost, independent proprietary hos- pitals have been more effective than other hos- pitals in slowing the annual rate of increase of costs. There are no statistically significant dif- ferences in annual rates of increase of expense per case among average hospitals in the other three of the four groups. Among independent proprietary hospitals, average annual in- creases were 1.2 percentage points lower than was the case among over hospitals. Over a 7- year period (1975 through 1981, the span of our data), this lower annual rate of grown pro- duces a cumulative compound savings of 8 per- cent, large enough by itself to account for the 4 percent average difference in the level of cost between proprietary independents and nonprofit independents. Figure 2 presents the comparative disper- sion of expense per ease among the four groups of hospitals. The comparative histograms are not adjusted for differences in location, case mix, and other factors among groups of hos- pitals. Relative to similar comparisons to be presented later, the distributions of expense per case among hospitals in each group are quite similar. The relatively high cost per case of proprietary chains is not readily apparent from the histograms and appears only as a re- sult of multivanate adjustment for differences in case mix and bed size.4 The moderate cost advantage of independent proprietary hospi- tals appears to result from a relatively high frequency of very low-cost hospitals within this group (22 percent with cost per case 30 percent or more below the national average).5 Utilization Rates After differences in case mix and other fac- tors have been taken into account, relatively small, if any, differences in average length of stay exist across the four groups of hospitals. Independent proprietary and chain-operated nonprofit hospitals have longer adjusted av- erage stays than other hospitals, but the dif- ferences represent only one to three additional days of stay for every 20 patients. Propne~y chains treat slightly fewer patients, on aver- age, and independent nonprofit hospitals slightly more patients, on average, than other hospitals. Occupancy rates are lowest for the average proprietary chain and slightly above average for the average nonprofit chain.6 The average chain-operated hospital ap- pears to be growing slightly faster than the average independent institution. Annual dis- charges grew by a halfa percentage point faster

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HOSPITAL OWNERSHIP AND COMPARATIVE COSTS 40 35 J 6 ~ 25 I us o z LU a: 10 5 o 40 35 u) 30 J ~ 25 o I o at UJ UJ 10 o 40 35 30 U. 6 cn 25 I o z C) CI: CL 15 10 i _ 5 _ o A. Proprietary Chains as. Non-Profit Independents =3 Propriesery Chains Non-Prof it I ndependen~s 30 20 , <70 70~9 90-110 llt-130 131-150 PERCENT OF NATIONAL AVERAGE B. Proprietary Independents vs. Non-Protit Independents ~3 Proprietary Independena _ Non-Profit Independents ,,, ~ L' <70 70~9 90-1 10 1 1 1-130 131-150 > 150 PERCENT OF NATIONAL AVERAGE C. NomProtit Chains vs. Non-Profit Independents =3 Non-Profit Chains Non-Profit Independents L L 150 PERCENT OF NATIONAL AVERAGE FIGURE 2 Dispersion of hospital expense per discharge among hospitals (years 1975 through 1981~. 327

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328 per year for the average nonprofit chain and by a full percentage point faster per year for the average proprietary chain than for inde- pendent nonprofit institutions. Compounded over the 7-year span of our data, these differ- entials in annual growth account for about 300 to 400 extra patients, respectively, for non- profit and proprietary chains. Charges per Discharge Earlier studies by Lewin et al. (1981) and by Pattison and Katz (1983) indicated that, at least for hospitals in California, Florida, and Texas, hospital charges per discharge are much higher for the average proprietary hospital than for the average nonprofit hospital. The differ- ence, according to these studies, is due to very large differentials for ancillary charges; routine charges per case differ by very moderate amounts for average hospitals in each group.7 Our results, shown in Table 2, condemn the findings of those earlier studies. Total charges per case, from our data, are substantially higher among proprietary hospitals (19 and 11 per- cent, respectively, for chain-operated and in- dependent facilities) and slightly higher among chain-operated nonprofit hospitals (3.5 per- cent) than among independent nonprofit hos- pitals. Routine charges per case are about the same, on average, across three of the four groups, but are moderately above average for independent proprietary hospitals. For ancil- lary charges per case, however, differences are quite large: compared to nonprofit indepen- dents, proprietary chains bil134 percent more per patient for ancillary services on average; proprietary independents bill 15 percent more; and nonprofit chains bill 5 percent more. Figure 3 compares the dispersion of expense and ancillary charges per case among hospitals in each of the four groups. For both types of proprietary hospitals, a very distinctive pat- tern is obvious a very high frequency (30 percent of hospitals) of very high ancillary charges per case despite a very low frequency (2 to 3 percent of hospitals) of very high ex- pense per case. In contrast, the dispersions of expense and ancillary charges among nonprofit hospitals are quite similar. Lacking data on units of ancillary services and charge/cost ra- tios by type of service, we cannot evaluate the FOR-PROFIT ENTERPRISE IN HEALTH CARE finding of Pattison and Katz, for California hos- pitals, that high ancillary charges per case among proprietary hospitals are due to a combination of high utilization and high markups. Margins on Revenue Using 1978 data for hospitals in California, Florida, and Texas, Lewin et al. (1981) found that proprietary hospitals achieved margins on patient revenue about 9 percentage points on average above those of nonprofit hospitals (+ 6.5 percent versus -2.7 percent) and after-tax margins on total revenue about 2.5 percentage points above those of nonprofit hospitals (3.7 percent versus 1.3 percent). Using 1980 data for hospitals only in Florida, Sloan and Vraciu (1983) found that proprietary hospitals achieved slightly lower after-tax margins on total reve- nue than those of nonprofit hospitals (5.4 per- cent versus 5.6 percent). Sloan and Vraciu argue that after-tax mar- gins on total revenue provide a more equitable basis for comparison of the "profitability" of proprietary and nonprofit hospitals than do pretax margins on patient revenue. The for- mer measure resects the gain to nonprofits from contributions and the burden to proprie- taryhospitals offederal and state taxes on prof- its. Our results, based on a nationally represen- tative sample of hospitals for the years from 1975 to 1979 and shown in Table 2, indicate that differences in margins across groups of hospitals are not as large as those reported by Lewin et al. or as small as reported by Sloan and Vraciu. Margins on patient revenue are 3 to 5 percentage points higher among proprie- tary hospitals than among nonprofit hospitals, and margins on total revenue are 1 to 2 per- centage points higher for proprietary hospi- tals.8 All intergroup differences are statistically significant. Figure 4 presents the comparative disper- sions of margins on patient revenue among hospitals in each of the four groups. Between 20 an<123 percent of proprietary hospitals have operating losses of more than 3 percent, com- pared to 31 to 35 percent of nonprofit hospi- tals. At the other end of the spectrum, 34 percent of proprietary chains have operating profits of

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HOSPITAL OWNERSHIP AND COMPARATIVE COSTS more than 8 percent, compared to 12 percent of independent proprietary hospitals and 3 percent of nonprofit hospitals. Differentials in relative frequency of operating profits of more than 8 percent do not change very much when one examines margins on total revenue (not shown in Figure 4~: 33 percent of proprietary chains versus 14 percent of proprietary inde- pendents and 8 to 9 percent of nonprofits. Data on comparative distributions are valuable be- cause they indicate that, despite modest dif- ferences among averages for the four groups, two to four times as high a proportion of pro- prietary hospitals achieve margins on total rev- enue of more than 8 percent than do nonprofit hospitals. DISCUSSION Our statistical results indicate that the truth lies somewhere in between the two polar po- sitions taken in the debate about the advan- tages and disadvantages of proprietary ownership of hospitals. On the one hand, our results tend to disprove the claim that pro- prietary chains can operate more cost effec- tively than the traditional independent nonprofit hospital as a result of economies of scale. A1- though independent proprietary hospitals op- erate at a 4 percent cost advantage relative to independent nonprofit institutions, proprie- tary chains operate, on average, at a 6 percent cost disadvantage. On the other hand, proprietary hospitals achieve smaller differential profit rates than some previous studies indicate. If one accepts the argument of Sloan and Vraciu that perfor- mance should be compared in terms of after- tax margins on total income, proprietary hos- pitals achieve a very small 1 to 2 points dif- ferential in net income as a percentage of revenue. Other aspects of our comparisons indicate areas in which proprietary hospitals have taken some additional advantage of the reimburse- ment system for hospital care. Despite our measures being adjusted for differences in case mix and other factors, proprietary hospitals op- erate with very high ancillary charges per pa- tient. Higher-than-average ancillary charges are most common among chain-operated pro- prietary hospitals. 329 Even though they operate with higher cost and higher markup of revenue over cost than other hospitals, proprietary chains managed to achieve a higher growth of admissions during the years from 1974 to 1981. This latter point illustrates the insensitivity of the market for hospital care to differences in cost and reim- bursement rates during the late 1970s and early 1980s. Until recently, the reimbursement system for hospital care has not encouraged efficient behavior. Cost-based reimbursement for Medicare, Medicaid, and in many locations, Blue Cross imposed a penalty for cost econ- omy. The mix of cost-based reimbursement for the large payers and charge-based rennburse- ment for others, however, tended to encour- age the type of differential pricing reflected in above-average ancillary charges among pro- prietary hospitals. The advent of Medicare's Prospective Payment System and various com- petitive strategies (preferred provider orga- nizations and competitive contracting) can be expected to provide stronger incentives for cost economy. Looking at data for the later years of the 1980s, one should not be surprised to see, in Me type of comparisons we have provided here, proprietary hospitals using different strate- gies, achieving lower than average costs, and deriving larger differentials on margins than they have obtained to date. NOTES Patients admitted for elective surgery and urgent care (e.g., acute myocardiac infarction or congestive heart failure) are those included. See Gaumer (1986) for a description of the selection of types of patients. Presuming a 12 percent annual inflation rate be- tween 1981 and 1985 and no change in relative costs, one would find an average difference of $400 per case today. 3When admissions, length of stay, SNF unit days, and outpatient visits are added to multiple regression models, to approximate a cost fimction specification, the estimated differences in cost per case among groups of hospitals remain virtually unchanged. Therefore, the hypothesis that chain-operated hospitals benefit from improved economic and technical efficiency is rejected by our results. 4Expense per case among proprietary chains is only 2 to 3 percent higher than among nonprofit indepen

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330 FOR-PROFIT ENTERTRISE IN HEALTH CARE 40 _ A. Proprietary Chains 35 _ 30 Cat In o I o Z 15 G UJ ?51 _ 20 10 o 5 _ 40 _ 35 _ 30 J Co 25 I o z C' 10 20 5 o if// Ancillary Charges _ Expense "R _ ~ _ ~ g 1 _ '/', ~ 11 _ i} ~ -,,,_ ALL <70 70~9 90-110 111-130 PERCENT OF NATIONAL AVERAGE B. Proprietary Independents ~//~1 Ancillary Charges _ Expense __ _a __ _. ~7/~11111 ~_ ~//~_111 ~//~ 150 An: 111-130 PERCENT OF NATIONAL AVERAGE 1 31 -150 >150 FIGURE 3 Comparative dispersion of expense and ancillary charges per discharge (years 1975 through 1981~. dents when no adjustment is made for bed size or case miss. Adjustment for regional location and catchment area characteristics is not sufficient to change the mag- nitude or statistical insignificance of differences com- puted from completely unadjusted data. The 6 percent differential reported in Table 2 results, therefore, pri- m=;ly from adjustment for case mix and bed size. Seethe cost advantage of proprietary independents rel- ative to independent nonprofits actually declines as the result of adjustment for bed size and case mix, from 10 percent to the 4 percent differential shown in Table 2. 6Because number of beds appears as an explanatory variable in the equations for length of stay and number of discharges, the sum of differences shown in Table 2 for length of stay and discharges can be interpreted as the average difference in occupancy rates across groups of hospitals.

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HOSPITAL OWNERSHIP AND COMPARATIVE COSTS 40 30 35 _ J 6 c,' 25 I IL 20 _ o ~ 15 _ Cal ~1 ~ _ s _ 35 [ 15 70 o 40 30 con 25 o I o FIGURE 3 Continued 20 15 10 5 o 7Pattison and Katz, using data not available from Medicare cost reports, attribute differences with re- spect to ancillary charges per case to a combination of high markups over cost on ancillary services by pro- pnetary hospitals and to high utilization of ancillary services by patients served in those institutions. 331 C. Non-Profit Chains ~3 Ancillary Charges _ _ 16 ~ Expense _ - , .... 131-150 >150 <70 _ 70~89 90-110 111-130 PERCENT OF NATIONAL AVERAGE D. Non-Profit Independents A// Ancillary Charges _ Expense _ ~ <70 70~9 90-1 10 111-130 131-150 >150 - ~_ - - PERCENT OF NATIONAL AVERAGE four data do not permit taxes on profits to be broken out as a separate element of nonoperating expense. In fact, it is likely that some proprietary hospitals did not include profit tax in their computation of net income on total revenue (see Lewin et al. [1981:58] on this point). Hence, our measure of margin on total revenue may overstate after-tax margins for proprietary hospi- tals.

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332 FOR-PROFIT ENTERPRISE IN HEALTH CARE 50 40 20 10 o ~3 Proprietary Chains Proprietary Independents Non-Profit Chains Non Profit Independents _ LEA ~ . >8 <-8 -8 to-3 -3 to O Oto3 3to8 MARGIN ON PATIENT REVENUE (%) FIGURE 4 Comparative dispersion of margins on patient revenue (years 1975 through 1979~. REFERENCES Ermann, Dan, and Jon Gabel (1986) Investor-owned multihospital systems: A synthesis of research findings. Ibis volume. Gaumer, Gary (1986) Medicare patient outcomes and hospital organizational mission. This volume. Lewin, Lawrence S., Robert A. Derzon, and Rhea hearties (1981) Investor-owned and nonprofits differ in economic performance. Hospitals July 1:52-58 Pattison, Robert V., and Hallie M. Katz (1983) Inves- tor-owned and not-for-profit hospitals. New England Journal of Medicine 309:347~3. Sloan, Frank A., and Robert A. Vraciu (1983) Inves- tor owned and not-for-profit hospitals: Addressing some issues. Health Affairs (Spring):25~7.

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