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Index A Abbott Laboratories, home health care services, 35 Accelerated Cost Recovery System, 54, 65-66, 90, 509 Access to care, see Health care, access to Adventist Health Systems, 29, 41 Aid, Inc., 253, 502 Alcohol treatment centers, 42, 100 Ambulatory care centers access to care through, 189, 226 characteristics, 35-36 charges, 91 competitive basis of, 94 cost savings through, 186 for-proBt, 36-37 growth trends, 36-3`, 226 innovations by, 91 ownership of, 26, 30-36, 40, 91 see also Birthing centers; Dialysis treatment centers; Primary/urgent care centers Ambulatory surgery centers characteristics, 35-36 design innovations, 41 equity investment in, 43 for-profit, 36 growth trends in, 36, 226 hospital-affiliated, 36 independent, 36 innovations by, 91 number of, 36 operations performed in, 36 American College of Physicians code of ethics, 161 American Health Capital, Inc., 43 American Healthcare Systems, 10, 29, 43, 503 American Hospital Association data on uncompensated care, 101-102 American Hospital Supply Corporation, 16 American Medical Affiliates, 502 American Medical Association code of edhics, 152, 153-154, 161, 166, 167, 213 policy on physician conflict of interest, 159 political role of, 241 American Medical International growth trends, 109-110, 251-253, 256-257 health maintenance plan, 144 home health care services, 35 number of beds, 252, 474 number of hospitals, 44, 250,474 nursing home ownership, 502 previous ownership of hospitals acquired by, 254, 255 tax obligations and payments, 53 teaching hospital acquisitions, 144 uncompensated care by, 114 American Medical Services, 503 American Medicorp, 251 Americana, 502 Anesthesiologists Board certification of, 131 compensation of, 166, 395, 429, 431, 452, 455 distribution by hospital ownership, 388 Angell Group, 503 ANTA, 502, 503, 509 AFUt Living Centers, 33, 501-503, 520 Associated Health Systems, 41 B Bad debt, see Health care, uncompensated Baxter Travenol Laboratories, 16, 35 Beds banking of, 307 excess of, 49-50, 64, 135, 187 investor-owned, 28, 30, 32, 80, 202, 250, 475 medical residents per, 142. 143 not-for-prof~t number, 29, 30, 32 543
Ji44 nursing home, 135, 137, 492-493, 507-508 regional distribution by ownership, 32 Behavioral Medical Care, 43 Beverly Enterprises acquisition activities, 2.53, 594 growth of, 509 HCA ownership of stool; in, 476 home health eare services, 35 number of nursing homes, 33, 501-503 = punitive actions against, 520 quality of eare by, 140 size, 3 stool; price gains, 507 Birthing centers, 39 Blue Cross/Blue Shield HMO operations, 44 Bond funding, tax-exempt, 10, 5.5, 59-60, 62-65, 67, 64, 81, 184, 197, 477 Brookwood Health Serviees, 251 C C. P. Rehab, 38 California corporate practice of medicine in, 166 effects of investor ownership on costs of eare in, 481-482 hospital acquisitions in, 105 hospital industry response to financial incentives, 290-302 hospital reimbursement in, 291 .\Iedieaid utilization rates in, 578 nursing home quality in, 519 uncompensated eare in, 102-103, 105, 188, 202, 298 Canada direct billing laws in, 160 health eare finaceing in, 218, 219 hospital ownership and financing in, 56 Capital, see Finaneial capital Capitation, conflict of interest in, 238 Care Corporation, 502, 503 Care Enterprises, 503, 528 Care Management, 509 Case mix differecees in hospitals, 271-277, 278, 281, 283, F 984, 28` indicators of, 962-260, 971-273 CENCO .502 Certificate of need bed banking for, 307 for primary eare centers, 44 restrictions on nursing homes, 91, 507-508 Charit! see Health eare, uncompensated Charter SIedica] Corporation, 39, 44, 109-110, 2.50 _.~_, 2.~4-2.5 ~ CIG\A health plan enrollees. 34 Cisil Rights Ounce, data on uninsured patients, 100 101 188 INDEX Clinics, ownership of, 40 Colorado corporate practice of medicine in, 166 financing uncompensated eare in, 119 Community Dialysis Centers, Ine., 38 Community Hospital of Sacramento, 2.53 Community Psychiatric Centers, 32 CompCare behavioral medicine hospital ownership, Comprehensive Care Corporation, 43 Connecticut, nursing home patient discrimination in, 118 Continental Care Centers, .502 Convalescent Serviees, .503 Corporate practice of medicine, 166, 174 Cost-based reimbursement, 50, 51, 56-57, 75, 77, 87, 94-95, 99, 156, 329, 498 Costs, see Finaneial capital, costs; Health care, costs; Hospitals, costs; Multihospital systems, costs; ^Nllrs~ng homes, costs D Debt financing, 54-55, 58-61, 71, 477 Dentists on hospital payrolls, 429, 4.51 Diagnostic centers, 38, 40 Diagnostic Centers, Inc., 38 Dialysis Clinics, Inc., 38 Dialysis treatment centers, 26, 38-40, 93-94 Doetor's Off~eenters, 37 E Eeonomic Beeoverv Tax Aet, 509 Eeonomic theories about health eare organizations, 5, 7, 19-~.5 Education, medical cross-subsidization of, 228-229, 24.5, 248 effects of investor ownership on, 142-150, 190-191, 245-246, 248, 2~6, 397 hospital commitment toward, 26.5, 273-276, 279- 280, 282, 285-987 public benefits of, 246 Equity financing, 41, 42, .50-51, 61-62, 67-73 Extendieare, 502 Federal Deficit Reduction Aet of 1984, 160 Federal Housing Administration 242 program, 59 Finaneial capital access to, 34, 47-50, 60-69, 65, 67, 184, 196, 283, 508 costs, 47, 56-57, .59-62, 64, 80, 197 earnings, 50, 57, 61 for-prof~t sources, 6, 9, 61, 477 from ~leclicare pay meets, .51, 64, 65, 140 future needs for hospitals, 49 government sources, 50, 57 grants, 50, 54-55. 57, 59-60, 99. 184
INDEX hospital requirements, 23, 49, 477 interest expenses, 50, 59 investment incentives, 52-53, 62 investor equity, 51, 61-62, 67-73, 191 nature and importance of, 47-73 not-for-profit sources, 6, 9, 61, 62, 64, 477 operating revenues, 50, 262-264, 273-277, 287 philanthropic, 50, 54-55, 57, 59-60, 63, 99, 118- 119, 184 policy issues regarding, 64-65, 196-197 return-on-equity payments, 50-51, 62, 65 sale of debt instruments, 50, 60, 67; see also Debt ~ . rlnancmg sources for health care organizations, 6, 9, 26, 43, 50-59, 61-65, 184, 201, 218, 218 tax deferral, 53-54, 62, 63 uses, 50-52, 119 working, of HMOs, 48 Finland, hospital ownership and financing in, 57 First Healthcare Corporation, 502 Florida costs of hospital care in, 481-483 hospital acquisitions in, 88, 105, 202, 303-321 hospital emergency rooms in, 109 hospital margins on revenues in, 328 uncompensated care in, 102-103, 105, 119, 188, 202, 319 Forum Group of Indianapolis, 144 Four Seasons Nursing Centers, 500, 502, 503 France, hospital ownership and financing in, 56 Freestanding facilities charges, 106 growth of, 91 hospital competition with, 91, 106-107, 116, 174 multihospital system operation of, 40 ownership, 106, 154-155, 175 quality of care in, 138 services, 106, 154-155 uncompensated care by, 106 see also Alcohol treatment centers; Ambulatory care centers; Ambulatory surgery centers; Birthing centers; Diagnostic centers; Dialysis treatment centers; Primary/urgent care centers G General Care Corporation, 251, 253 General Health Services, Inc., 251, 253 George Washington University Hospital, 144, 145 Geriatrics, 502 Government funding of health care, 11-13, 57 health care organizations, 17, 19, 57 obligations concerning uncompensated care, 113, 110-116, 195, 228, 23o role in health care, 5, 12, 235 stimulation of HMOs, 33 545 subsidization of not-for-prof~t hospitals, 62-63 see also Hospitals, government Group Health Association of Washington, 33 Group Health Cooperative of Puget Sound, 33 GWU Health Plan, 144 H Harvard Community Health Plan balance sheets, 47, 48 flow-of-finds statement, 50-51 Health benefits programs, 27, 41 Health care access to, 97-126, 18(-189, 225-232 amenities, 13, 107, 236 as a commodity, 11-12, 14-15, 183, 220, 233-237, 244 as a social good, 12-15, 182-183, 220 conflicts of interest in, 15, 152, 158-161, 163-164, 197, 214, 217, 219, 237-245, 248, 396 consolidation of providers, 43 costs control of, 91 data sources on, 92-93 definition and measurement of, 74-76 distribution of, 209-210, 213, 210, 220, 228, 230, 231, 247 effect of for-pro~t health services on, 93-94 effect of investor-owned hospital systems on, 480-483 findings about, 185-187 for capital, 47, 51, 56-57, 59-62, 64, 68-69, 71 ,2, 80, 197 hospital post-acquisition increases in, 87, 480 481 measures of, 261-264 monitoring trends in, 92-93 recovery of, 98-99, 113 savings through ambulatory care centers, 186 to community, 80-81, 84, 94 see also Hospitals, costs; Nursing homes, costs data sources on, 92-93, 101-102, 188, 261, 262, 285-286, 403, 422-423 economic incentives in, 192-193 entry barriers, 22, 23, 24 ethical issues, 3-4, 11-16, 17, 111-116, 151-153, 182-183, 192, 209-249, 396 expenditures, 3, 5, 35, 38 financial capital sources for, 6, 9, 26, 43, 50-59, 61-65, 184, 201, 218, 219 government funding for, 6, 9, 11-13, 55 government role in, 5, 12, 235 growth trends, 3, 26-29, 31-38, 47-73, 88, 90-91, 108, 190, 226, 250-259, 290, 292-294 information asymmetry in, 13, 20-21, 23-24, 139 140, 236-237 insurance effects on, 11 key elements of, 13
546 market forces in 11-1_, 19, _88 minimum level of _30 231 23~-236~ _48 model system of _11 _14 monitoring of 92-93 112, 137-139, 156, 190. 199 900 multi-tier ss stem in. 1_. 13, 17~ _23 net types of pros iders in, 3~-39 organizational changes 27 o~erutilization of 239-_40 physician entrepreneurism in, 15. 43~4. 151-170. 19, -198, _1.5 planning international!!. 56-57 policy issues 4, 14-15` 62-65, 98, 99, 110, 159 16~ 199, 195-197, 905, 209-_23, 318-320 political dominance in' 246-248 price basis for. 74- 75 comparisons 80-81 competition, 183 effect of uncompensated care on, 76, 94, 118 findings on 185-186 increases following hospital acquisitions, 87 inforrnatioI1 restriction of, 234 per case and per da`?, 80 profit issues in, 3-25? 185-187 quality effects of in`,estor-owned multihospital systems on, 37~-376, 483-487 for-profit status and, 90, 127-141 in freestanding facilities, 138 in hospitals 127-134, 189-190 in not-for-profit organizations, 92 in nursing hones, 131-137, 140, 510-521, 530 531 indicators of, 127-134, 139, 189-190, 376, 487, 515, 519 monitoring, 92-93, 112, 137-139, 156, 190, 199 900 outcome measures of, 133-135, 139, 520 patient judgment of, 13 physician evaluations of, 130-132, 189, 396-397, 399 physician responsibility, 15, 171-174, 237-245 refusal for financial reasons, 98 regulation of, 12, 26-27, 135-136, 242, 246-247, 272-273, 078, 280-981, 284, 286 sectors, 19' 24 services configuration and control changes, 26~6 new, 38-39, 64 outside of hospitals, 27 pricing of, 13, 74-76, 80, 87, 185-186, 277, 287, 994-296 unnecessary, 13, 17, 158-160 vertical integration of, 39-41 see also Hospitals, services structural changes in, 26-46, 92, 260 I.\'DEX tar subsidization of. 903 trends in. 43-~. 198-199 uncompensated ability to provides 91. 465 Shouts pros ided b! hospitals. 98 as percentage of gross patient res enues, 103 111 by for-prof~t hospitals _13. 465-466 by freestanding facilities. 106 by geographic location 99-104. 188 by got ernment hospitals, 98. 114 by ins estor-owl~ed corporations, 114' 117. 465 466. 483 by I~lultihospital systems 103~ 486 by not-for-profit hospitals. 98, 114, 116. _25. ~ 232-233. 465-466 by teaching hospitals. 10~ 146 cost recox erg 98-99. 113 cross-subsidization of, 99, 106-10~. 113. 115. 11~-118. 192-193' 225-~26~ 231-232~ 31_. 486 data sources on 101-109 definition of. 98, _0_ effect offreestar~ding facilities on. 106-10` effect on hospital prices, 76, 94. 118 effects of ownership change on, 103, 317, 319 factors affecting burden of, 20_. 465 financing of, 98-99, 116, 119, 199-196. 228. 935. 24`, 465 government obligations concerning 113, l lS 116,195,228,935 harm to hospitals providing, 60, 98. 117-118. 188~ 231, 465-467 in California, 102-103, 105, 188, 202, 298 in Florida, 102-105, 119, 188, 202 in Kentucky, 117 in Maryland and New Jersey, 119 in Tennessee, 102-103 in Texas, 102-103 in Virginia, 102-103, 119, 188 information needs, 112 legal obligation to provide, 98, 112-115, 117, 228 measurement of, 100-104, 111, 465~67 providers of, 99-104, 188, 194, 228, 298, 465 467 public expectations concerning, 13, 98 scope of the problem, 97-116, 194-196 strategies for continuing, 106, 119, 195-196, 230 strategies for reducing, 104-110, 117, 119, 202, 312 tax status and, 98, 113-117, 193-194, 196, 203 see also Home health care; Ownership/affiliation comparisons Health Care Financing Administration disclosure requirements of, 159 professional review organization, 137, 139' 160 Health care organizations
INDEX access to capital by, 34, 47-50, 60-62, 65, 67, 184, 196, 283, 508 assets, 47-49, 52-53 behavior of, 5-6, 9-11, 13-14, 20-23, 93, 260-289 combined provider/insurance functions of, 44 competition between for-profit and not-for-profit, 117-118, 183, 232-233, 247-248, 265, 270, 2~2-275, 278, 280-281, 284, 462~64 constraints on, 10-11, 88, 137 credit ratings of, 61 debt financing by, 10, 50, 54-55, 58-65, 67, 71, 184 definitions of, 16 distinctions between for-profit and not-for-prof~t, 5-11, 86, 184-185 diversification by, 39-42, 44 earnings, 50 economic theories about, 5-6, 19-25 efficiency of, 9, 16, 22-24, 75, 186-187, 225, 296, 312, 317-318 expense types, 74 government capital sources for, 57 characteristics, 17 economic rationale for, 19 growth of, 3, 26-38, 47-73, 88, 90-91, 108, 190, 226, 250-259, 290, 292-294 hybridization of for-prof~t and not-for-prof~t, 10, 26, 41-43, 44 incentive bonus arrangements with physicians, 153, 156-107 investor-owned, 3-10 access to care under, 97-126, 225-232 advantages and disadvantages of, 3-4, 97, 187, 226 concerns about, 4, 13, 97-126, 187, 225, 232 efficiency of, 23-24, 75, 18~187, 225 management of, ~7, 16, 23 mission, 6, 60 physician exit and voice mechanisms in, 176-178 profit distribution, 6, 184 profitability incentives, 7, 184-185 rationale for, 21 research activities of, 148 revenue sources, 6, 52 social obligations, 226-230 stool; options, 16-17 subsidization of health care, 227 taxes, 6, 227 types, 183 legal differences in, 184 legal responsibilities of, 98, 112-115, 117, 228 management contract arrangements among, 40-42, 255-256, 271-2-15, 278, 280-281, 284, 286 new types of, 35-39 not-for-profit, 6-10 advantages of, 8, 62-63 547 capital sources, 6, 61, 62, 64 characteristics, 7-8, 232-233 corporate reorganization of, 184 efficiency, 9, 22, 75, 186-181 financing, 8, 10, 17, 62-63 future of, 194 goals and ideals, 8, 75 investment in unneeded equipment and facilities, 9, 22 management of, 6, 22-24 mission, 6, 60 nondistribution requirement, 6, 7-8, 10, 20-21, 75, 184 protection of from competition, 232-233 purposes, 6, 8, 22 quality of, 22 rationale for, 20 revenue sources, 6, 20, 24 tax status, 6, 8, 10, 20, 63, 98, 113-115, 184, 227, 233 tax-exempt bond funding by, 10, 55, 59-60, 62 65,67,81, 184, 197 obligations to provide uncompensated care, 98, 112-115, 117, 228 ownership diversity, 4-5, 16 physician investment in, 153-156, 159, 162-163, 197-198 physician relationship with, 10-11, 15-16, 24 social responsibilities of, 97, 113, 193-194 tax obligations and payments, 53-54, 62, 193-194 Health Care Retirement, 503 Health Central Corporation, 41 Health Insurance Plan of Greater New York, 33 Health Maintenance Organization Act of 1973, 33 Health maintenance organizations, 33-34 balance sheets, 47-49 Blue Cross/Blue Shield, 44 bonus incentive arrangements in, 158, 238 flow-of-funds statement, 50, 51 hospital use rates of, 159 limitation on care by, 238 Medicare market for, 34 multihospital system operation of, 40, 41 multistate, 34, 44 negative aspects of, 219, 238 ownership of, 26, 40 Health Resources Corporation, Inc., 39, 253 Health status indices, 139 Health Ventures, 42 Hill-Burton program, 59, 98, 117 Hillhaven nursing homes operations, 33, 501-503, 509, 520 Home health care, 26-2~, 34-35, 40, 138, 159 Horizon Health. 253 Hospice Care, Inc., 39 Hospice care, 38-39, 121 Hospital Affiliates International, Inc., 87, 251, 253
548 Hospital Association of America diversification by, 40, 42, 476 home health care enterprises, 35 hospital acquisition costs, 87 growth trends, 109-110, 250-253, 256-257, 305 number of hospitals, 29, 44, 250, 251, 474 occupancy rates, 95 psychiatric hospital ownership, 32, 44, 144 research grants by, 148 size of, 3 sole community provider hospitals of, 174 tax obligations and payments, 53 teaching hospitals, 144, 145 uncompensated care by, 114, 117 Hospitals accounting age, 293, 294 accreditation of, 105, 128-129, 189, 364-367, 374, 377-379, 382-383, 3~7-379, 382-383 acquired available resources of, 313, 318 characteristics of, 299-301, 303-316, 475-476 price increases at, 87, 319-320 regional characteristics, 313 acquisition changes aDcer, 87, 105-106, 203, 301, 314-318 costs of, 80, 186, 319-320 following contract management, 255-256 in California, 105 in Florida, 303-321 profitability aDcer, 87-88, 301-316 through pooling of interest, 258 acquisitions by, 303-321 activity and productivity, 262, 264, 283-287 administration responsiveness, 132, 178 administrators, 172, 415 ambulatory surgery by, 36 amenities offered by, 13, 107 antibiotic use review by, 380 bed capacity, 28, 30, 32, 80. 250-252. 25a 265 270, 272-276, 279-780, 282-283, 285, 475 bed excess, 49-50, 64, 135, 187 behavioral medicine, 42 board chairman responsibilities, 132-133 board membership, 177-178 board responsibilities, 133 capital requirements, 23, 49 capital structure of, 263-264, 280-283, 287 capitalized leasing of, 25& case flow in rate-setting states, 286 case-mix differences in, 262-26a, 271-278, 281, 283, 284. 287, 365-367, 374, 458-473 certificate of need for, 23 charges, 93. 328, 344-349 chief executive officers, 406-408, 414 chief of staff, 409, 416 closures, 105, 109-110,_56-2~7 community interaction of, 458~73 INDEX compensation methods, 393-397 competition between, 117-118, 265, 270, 272-275, 278, 280-281, 284, 462-464 competition with ambulatory care facilities, 91, 106-107, 116, 174, 462, 464 construction trends, 28, 251-253 construction, funding for, 54-55, 57-59, 119 contract management of, 40-42, 255-256, 271-275, 278, 280-281, 284, 286 corporate restructuring of, 41, 307 cost containment committee, 407, 409, 419 costs administrative, 273, 277 allocation methods, 75, 77, 94, 95 data sources on, 323 educational, 119 incurred under diagnostic-related group, 40 input, 265, 272, 279, 282, 285 measures of, 261-264 medical education, 287 of acquisitions, 80, 87-89, 186, 319-320 of care in, 480-483 of equipment, 119 operating, 290 regression analyses of, 322-353 reimbursement for, 56-57 research, 119 cross-subsidization by, 99, 106-107, 312 data sources on, 261, 262 decision making in, 171-172, 175-178, 402-421 director of medical education, 408, 417 discharge information on basis of ownership, 340 343 diversification by, 42, 44, 464 divestitures by investor-owned hospital companies, 256-257 drug utilization review by, 380 dumping of patients by, 104, 119 economic performance factors, 26.5 effect on competitive climate of communities, 462 464 efficiency post-acquisition, 317-318 efficiency pre-acquisition, 312 evaluation of quality, by physicians, 130-132, 189, O99 expansions, 251-253 expenses administrative, 77 after acquisitions, 87, 317-320 analyses of, 92 average annual rate of increase, 77 categories, 296 depreciation and amortization, 52, 59 for drugs and supplies, 80 occupancy effects on, 77 operating, 77, 296-297, 312 patient care, 186
INDEX personnel-related, 80 studies of, 76-80 facilities emergency room, 104, 105, 107-109, 117, 122, 298, 46~66 pharmacy, 108, 125, 295, 298 premature nursery, 108, 109, 118, 121, 465 financial arrangements with physicians, 393-396 financial screening of patients, 104 functional strategies governing boards, 405-406, 411 governance, physician participation in, 402-421 government capital sources for, 50 construction Finding sources, 59 contract management of, 41 Medi-Cal patients in, 295, 297-298 uncompensated care by, 98, 114 growth in California, 292-294 influence of physicians in, 157, 171-181, 198-199, 470-471 international ownership and financing, 55-57 investor-owned capital sources, 9, 50, 61 cost of equity financing, 51, 61-62 definition, 31, 224 distribution by state, 31 efficiency of, 225 expenses, 76-80 financial strategies, 287, 290-302 grant eligibility of, 142-143 growth rate, 28 lengths of stay, 77, 93, 9S local property taxes, 53 locational preferences of, 86, 103-104, 183-184, 187, 307 market share, 30 medical residency programs in, 142-144 medical staff composition, 389, 400 Medicare capital payments to, 51, 65 number of, 28, 44, 183 patient outcomes in, 140, 367 physician attitudes toward, 394, 396-398 physician involvement with, 386-392 pricing strategies, 287 profitability, 287 quality of care in, 367 research in, 142 response to financial incentives, 29~301 return-on-equity payments, 50-51 revenue sources, 9 size of, 29, 255 tax deferral by, 54, 62 taxes, 119 uncompensated care by, 213, 483 see also Ownership/affiliation comparisons, hospitals 549 joint ventures of, 41, 43, 1~5 leasing arrangements with physicians, 175, 393 legal responsibilities, 98, 105, 117 lengths of stay in, 157, 159, 992, 338-339, 359-363 long-range planning committee, 407, 409, 420 management of by physicians, 406-408 markups, 84, 262, 277-280, 287 Medicaid caseload in, 305, 306, 312, 313, 317 medical education commitment of, 265, 273-276, 279-280, 282, 285-287 medical resident/bed ratio, 142, 143 medical staff applications, 423-42S, 430 committees, 407-409, 418, 420 qualifications, 128-130, 131 salaries and benefits, 80, 312 size and composition, 174, 313, 422-426, 430, 434, 440-445 Medicare capital payments to, 51 Medicare case mix in, 359 membership in alliances, 41 methods for assuring payment, 467 modeling of behavior of on basis of affiliation and ownership, 260-289 monitoring care in, 137-138 monitoring physician patterns of care by, 156 mortality rates by type of, 357-365, 367-368, 371, 273 net margins, 9, 201-202 not-for-prof~t beds, 29, 30, 32 capital, 9, 80 characteristics, 232-733 expenses, 66, 76-77 financial incentives, 290-302 management by investor-owned systems, 41 price differentials between for-profit systems and, 80, 464 protection from for-profit competition, 232-233 response to financial incentives among, 290-303 revenue sources, 9, 42, 66, 93, 233 tax exemptions, 114, 116, 157 uncompensated care by, 98, 114, 116, 225, 228, 232-233, 465-467 nursing support adequacy, 132, 189, 397 obligations to provide uncompensated care, 112 115 occupancy rates, 39-40, 49, 64, 77, 87, 94, 95, 186, 283, 286, 292, 301, 306-307, 312, 326 organizational mission, 354-374 outcomes relative to size of, 359 ownership, 4, 28, 40; see also Ownership/aff~liation comparisons, hospitals patient selection strategies, 262-263, 265, 272-275, 281, 284, 287, 312 payer mix in, 391 pricing
500 INDEX after mergers and acquisitions. 8 ~ differences, `~-~6, 185-186, 294-_96, 464 effects of uncompensated care on, ~6. 94~ 118 studies of, 76, 80-81, 82-83 profitability, 8~-88, 93, 962, _/ ~-_80. 28~. 29_ 994, 311-316~ 328 proprietary, 97, 28, 108, 118, 399 psychiatric, growth trends, 31, 474, 476 quality assurance activities, 498 qualit! of care in, 127-134 reactions to prospective pax ment system 156 readmission rates by type of, 35~-365. 3~_ regional practice differences, 265, ~ ~ 2-9 ~ 5~ ~ ~ 9, 282, 285 regulation of, 270, 272-273. 278,280-281, 984, 986 renovations, 251 reporting systems, 92 response to financial incentives, 190-302 revenues ancillary services, 84, 88 deductions from, 297 gross patient, 103 margins, 99, 328-329, 350-353 measurement and comparison, 75, 261, 987 Medicaid, 140 nonoperating, 93 nonpatient, 76, 85, 86, 99 operating, 262-264, 273-277, 287 patient, 93 post-acquisition, 318-320 pre-acquisition, 312-313 sharing with physicians, 165 sources, 99, 140 see also Financial capital room rates, 84 services ancillary, 81, 84, 125-126, 225, 283, 295, 298, 312, 318, 328, 329 community costs of, 94 factors associated with, 30 obstetrics, 104, 107, 108, 109, 118, 276, 288, 298, 465 outpatient, 108, 109, 122, 155, 283, 288 profitable, 276, 313 room and board, 295 types of, 26, 75 unprofitable, 107-108, 189,276, 465 similarities among, in ownership and affiliation, 287 siting and service area characteristics, 268-271 social responsibilities of, 212 sole community providers, 105, 117, 187, 202, 268, 272, 273-275, 277, 278, 280, 281, 284, 287 statistical methods for evaluating differences in, 369-371 strategies for reducing uncompensated care, 104 110 teaching acquisition of by ins estor-owned multihospital systems, 288-289 cross-subsidization of education and research by, 143. 150 financial pressures on, 146 functions and goals of, 143-1~. 146-147 negotiations between in`,estor-owned companies and. 145 number and size of, 150 ownership-related fears of, 145-146 uncompensated care by, 10~. 146 technical resources and equipment adequacy, 13_ third-party coverage patterns. 270 total net margins of, 86 uncompensated care provided by!. 60, 76, 97-116. 187-188 utilization patterns, 261, 265, 270. 277-275, 279 280, 282-283, 285, 326-328, 391-399 utilization review by, 428 vertical integration of services by, 44, 464 wage indices associated with locations. 268-269 see also Multihospital systems; Ownership/ affiliation comparisons Humana Heart Institute, 148 Humana, Inc. actuarial risk assumption by, 41 acute care hospital ownership, 44 balance sheet, 47, 49 capitalized lease arrangements, 258 dividends, 61, 70 flow-of-funds statement, 50, 52 growth trends, 109-110, 250-253, 256-257 interest rates on long-term debt, 61 market effects on facility ownership, 288 mergers, 251 number of hospitals, 250, 474 primary care center ownership, 37-38, 40-41 relationship with Symbion, 149 research grants by, 148 revenue sources and uses, 50, 52 size, 3, 474 stock options, 17, 61 tax obligations and payments, 53 teaching hospital affiliations, 144 uncompensated care by, 114 HumanaCare Plus program, 41 Hyatt, 251 Independent practice associations, 238 Insurance effects on health care market forces, 11
INDEX effects on physician volume of services, 14 population without, 116-117, 225 risk pool differentiation, 234-235 see also Health benefits programs Insurance companies multihospital system purchase of, 41 with HMO subsidiaries, 16 Insurance Company of North America, 253 Intermountain Health Care Inc., 42 J Jarvik-7 artificial heart, 149 Joint Commission on Accreditation of Hospitals multihospital system compliance with, 375-384 see also Hospitals, accreditation of K Kaiser Foundation Health Plan, Inc., enrollees, 34 Kaiser Permanente, 33 Kentucky, uncompensated care in, 117 L Laurel Grove Hospital, 253 Leisure Lodges, 502 Lifemark, 251 Lutheran General Hospital (Illinois), investor-owned subsidiary of, 42 M Manor Health Care, 503, 528-529 Maryland investor-owned hospitals in, 476 uncompensated care in, 119 Massachusetts investor-owned hospitals in, 476 nursing homes in, 118, 514, 522 Maxicare Health Plans, Inc., 34 Medic-Homes, 502 Medicaid discrimination, 528-529 effects on hospital growth, 26 effects on nursing home growth, 497-498, 500 expansion of coverage, 498-498 fraud, 157 market created by, 229 payments to nursing homes, 88, 91, 497-501 Medical Care International, 36, 43 Medical laboratories, 40 Medical office buildings, multihospital system ownership of, 40 Medicare capital payments to hospitals, 51, 64 case loads in hospitals, 305 case mix, patient outcomes relative to, 359 case-mix index, 92, 95 contractual allowances, 297 cost increases at acquired hospitals, 87 551 cost reports, 92 effects on hospital growth, 26 effects on nursing home growth, 497498 End-Stage Renal Disease Program, 26, 38-39 expansion of coverage, 497-498 fraud, 156, 161 Hospital Insurance Trust Fund, 51 market created by, 229 market for HMOs, 34 nursing home reimbursement policies, 95, 498-501 patient outcomes, 354-374 physician acceptance as full payment, 14 Prospective Payment Assessment Commission, 92 reimbursement policies, 27, 35, 64, 65, 76, 95, 166, 183, 187, 190, 197, 199, 226, 305, 329, 498 return-on-equity payments, 50-51, 62 treatment of bad debts, 94 Medicenters of America, 500, 502 Memorial Care Systems, 42 Memorial Health Net Providers, 42 Methodist Hospital (Oklahoma City), 144 Minnesota nursing homes admission discrimination in, 118 quality in, 514 Mission Services Corporation, 43 Models competitive market, 19 economic, 19-24 Monterey Life Systems, 502 Multihospital systems access to capital, 61, 477~78 accreditation trends of, 364-367, 375-384 acquisitions of by other chains, 251 administration of hospitals in, 467-470 advantages and disadvantages of affiliation with, 27, 60-61, 375-376, 469-470, 477~80, 486 bond ratings, 60-61, 478 borrowing power, 26, 60, 477 case mix, 368 characteristics of hospitals in, 461470 comparison of investor-owned and not-for-profit, 29-32 compensation arrangements with physicians, 422- 457 diversification by, 478479 economic benefits of membership in, 477~79 economic perfonnance of hospitals in, 260-289 economies of scale, 287-788 effects of membership in, 467468 investor-owned access to care in, 105-106, 483-486 accreditation status, 367-368 acquisitions, 105-106, 117, 250-256 advantages and disadvantages, 105, 189, 329, 476477 balance sheet, 47, 49
552 INDEX beds, 30, 32, 80, 475 capital costs, 80 capital raising by, 61 chief executive officer compensation, 476 closures by, 109-110 control of, 474 costs of care in, 480-483, 486 ~ diversification by, 40, 476, 486 dividend yields, 72 drug and supply expenses, 80 economies of scale, 77, 80 effective tax rate, 53 expenses, 95 financial performance, 416, 486 flow-of-funds statement, 50, 52-54 freestanding facility operation by, 40 growth trends, 2~-29, 108, 190, 250-259, 290, 375, 474-480, 486 hospital size in, 30 information sources on, 250 lender preference for, 55, 60 lengths of stay in, 95 locational preferences, 29-30, 103-104, 105, 255 management of not-for-profit hospitals, 41 markup by, 480 medical staff size and composition, 431 number of hospitals, 30, 300, 474 occupancy rates, 94, 105 patient outcomes in, 367-368 physician compensation arrangements in, 430, 432 physician exit and voice mechanisms in, 176 physician privileges in, 176, 431-432 price differentials between not-for-profit hospitals and, 80 pricing strategies, 294-296 profitability of, 290, 476 quality of care in, 36~-368, 476, 483-486 revenue sources, 196 services offered by, 108-109, 480, 486 size. 99 staffing of, 176. 479433 tax obligations and payments, 53-54, 62, 195 teaching hospitals, 143-149 uncompensated care bv 103 486 ,, , vertical integration of services by, 40 local control in, 61, 467-470 medical staff sizes, 422-457 modeling of behavior of, 260-289 not-for-prof~t beds. 29, 30, 32 capital raising by, 61 corporate restructuring of, 42 diversification by, 40 fornication of, 98-29 geographic distribution of hospitals, 287 government subsidy of, 69-63 investor-owned subsidiaries of, 42 management of for-prof~t hospitals by, 41 management of, 468469 number of hospitals in, 29, 30 religious/secular breakdown, 29 vertical integration of services by, 40 occupancy rates, 39-40, 77, 95 personnel management by, 479 physician privileges, 422-457 planning by, 479 political power of, 479 pricing strategies, 277 quality of care in, 375-377, 483-487 revenue sources, 41 size, 29 types of health services, 26 vertical integration of services by, 39 see also Hospitals; Ownership/aff~liation comparisons N National Association of Private Psychiatric Hospitals, 44 National Health Care Affiliates, 503 National Health Corporation, 503 National Health Enterprises, 502, 507 National Health Planning and Resources Development Act of 1974, 118 National Health Services, 502 National Medical Care, 38 National Medical Enterprises diversification by, 476 educational endowments by, 148 growth trends, 109-110, 250, 252-257 home care enterprises, 35 number of hospitals, 44, 2.50, 474 nursing home operations, 33, 528 psychiatric hospital ownership, 32, 44 revenue sources, 40 tax obligations and payments, 53, 114, 119 teaching hospital construction, 144 uncompensated care by, 114 vertical integration of services by, 40 National Medical Home Care, Inc. 35 Netherlands, hospital ownership and financing in, 56 New Jersey College of Medicine and Dentistry of, 144 investor-owned hospitals in, 476 uncompensated care in, 119 New York investor-owned hospitals in, 476 nursing home costs in, 522 North Carolina, financing uncompensated care in, 119 Nurses per patient, 130, 131 Nursing homes access to care in, 110-111, 189, 526-531
INDEX acquisition activities, 90 bed supply, 135, 137, 492-493, 507-508 certif~cate-of-need restrictions, 91, 507-508 chains, 90-91, 505, 024-525 charges per diem, 88-89 comparison of hospitals and, 134 constraints on, 88 costs o administrative arid general services, 89-91, 530- Ohio 531 escalation of, 493 function studies and behavioral and market models, 521-524 patient care, 89-91, 530-531 effects of long-term-care demands on, 506-507 expenditures, 498 extended care facilities, 497 financial capital access, 499, 508 financial constraints on, 137 growth of, 32, 492-510 health planning requirements for, 507-508 heavy-care patients in, 110-111, 118, 189, 508, 526 history of, 493-501 hospital expansion into, 27, 40 intermediate care facilities, 511 investor-owned, 26, 33, 90-91, 476 licensure and certification deficiencies and complaints, 517-520 Life Safety Code, 504, o10 Medicaid reimbursement policies toward, 95, 500, 504-~06 Medicaid revenues, 88, 500 Medicaid/private-pay differential in charges, 89 Medicare/Medicaid ejects on, 497-498 merger rules, 509-510 "mom and pop" facilities, 504, 505, 509-510, 512 multi-institutional system growth, 33 number of, 32 occupancy rates, 88, 110, 508 ownership, 4, 26, 32-33, 89, 111, 134, 501-503, 510-52~; see ado Ownership/~iliation comparisons, nursing homes patient discrimination by, 110-111, 117, 189, 493, 526-529 payment system, 88, 93, 118, 135, 136, 187, 499 physician role in, 135, 137 placement decision making, 114, 493 profitability, 90, 91, 499-500, 507-508 proprietary sector share, 32 public policy on, 493-510 quality of care in, 134-137, 493, 510-521, 530-531 regulation of, 135-136, 493, 503-504 reporting systems, 92 residents, 111, 118, 493, 528 revenues, 140 scandals, 496, 500, 503 spending differences per patient day, 514-517 553 structural changes in, 492-542 tax policies concerning, 509-510 utilization, 49`, 506 vertical integration of services by, 505, 509-510 see also Ownership/affiliation comparisons, nursing homes Medicaid patients in nursing homes by ownership, 118, 528 nursing home costs in, 522-523 nursing home quality in, 519, 530 Old Age Assistance, 494-495 Omnibus Reconciliation Act of 1980, 35 Omnimedical, 38 Ownership/affiliation comparisons access to care on basis of, 97-126 ambulatory surgery centers, 36 conclusions about, 191-192 diversity of U. S. health care organizations, 4-5, 16 freestanding facilities, 106, 154-150, 175 geographic patterns, 183-184 government role in, 5 health care costs on basis of, 74-96, 185-187, 322 353, 480-483 hospitals accreditation trends on basis of, 128-129, 189, 364,367, 374, 378-379, 382-383 activity and productivity on basis of, 283-287 acute care, 28 admissions by sources of payment and, 101 bed capacity on basis of, 30, 32, 80, 250-251, 270, 272-275, 279-280, 282-283, 285 Board chairman responsibilities on basis of, 132 133 Caesarean section rates by, 134-135, 138 capital structure on basis of, 263-264, 280-283, 287 case-mix differences on basis of, 271-278, 281, 283,284, 287, 366-367, 374 case studies of, 458-473 changes in, 305 charge structure according to, 296, 298, 328 closures on basis of, 109-110 comparison of nursing home ownership and, 134, 187 competition on basis of, 265, 270, 272-275, 278, 280-281, 284 conflicts of interests in, 159-160 contract management on basis of, 271-275, 2~8, 280-281, 284, 286 cost comparisons relative to, 322-353 cost-effectiveness on basis of, 290 deductions from revenue on basis of, 297 discharge information on basis of, 340-343 distinctions between, 5-11, 86
- - ~ IA'DEX economic performance on basis of. 060-_89 effects on functional strategies and economic performance, 960-989~ 385-401 expense comparison by, 76-80, 186, 9,3-9, ,. 31,-318, 3_~-30l, 3~-33l expenses relative to, 7 6-80, 93. 9~3-_ 77 ~ 296- 09,, 370-396~ 3~-33, facilities by type of, 1_1-126 financial capital structure according to, _63-264, 280-283, _87 input costs on basis of, 265, 972, 279, 282, 285 JCAH accreditation by, 129 lengths of stay on basis of, 292, 294, 338-339 margins on revenue on basis of, 328-329, 350 303 markup on basis of, 81, 84, 277-280, 28`, 310 medical education commitment on basis of, 265, 0,3-2,6, 279-280, 282, 285-287 medical staff differences on basis of, 140, 176, 189~ 312, 422426, 434, 440-445, 451 mortality rates by, 357-358, 371, 373 number of residents and trainees by type of, 143 nurse/patient ratio by type of, 131, 189 occupancy rates on basis of, 292, 301, 306-307, 319, 326 operating costs on basis of, 290 operating revenues on basis of, 273-277, 287 patient outcomes on basis of, 133-134, 189-190, 354-374 patient selection according to, 262-263, 265, 272-275, 278, 281, 284, 287 physician characteristics and practice patterns according to, 386-38 7 physician compensation on basis of, 393-397, 436437, 401~57 physician distribution according to, 388 physician evaluation of quality by type of, 130 132, 189 physician participation in governance, 402-421 physician privileges on basis of, 128-129, 386, 424~25, 427428, 430, 438439, 450 physician utilization on basis of, 392 physicians on governing board on basis of, 405 406 policy issues arising from changes in, 318-320 potential for future success on basis of, 288-289 pre-acquisition, 253-255 pricing strategies according to, 294-296 profitability on basis of, 85-86, 93, 277-280, 287, 292-294, 307-320 psychiatric, 4, 2~27, 30-32, 40, 144, 474, 476 quality comparisons on basis of, 127, 138-140, 189-190, 376-377 readmission rates by, 357-359, 365, 372 regional practice differences in, 265, 272-275, 279, 282, 285 regulation on basis of, 2~0. 278 280-281, 284, _86 relationship to quality, 197, 138-140, 189-190 revenue sources by, 100 services and facilities offered by type of, 108 109, 121-126 siting and service area characteristics on basis of, 268-2~1 specialty distribution of physicians by, 388, 434. 4414 structural changes in California according to, 291 teaching, 142-149, 988 third-party coverage on basis of, 270 uncompensated care as percentage of gross patient revenues by, 103 utilization patterns on basis of, 270, 272-275, 2,9-280, 282-283. 285, 326-328 implications of differences in, 185 investor-owned/not-for-profit distinctions, 6, 9-11. 184-185 length-of-stay differences by. 77, 95 medical education implications of, 142-150, 190 191, 245-246, 248, 276 medical residency programs and, 142, 143 multihospital system advantages and disadvantages, 469-470 nursing homes comparison of hospital ownership with, 134 costs by, 89-90, 186, 521 patient discrimination on basis of, 528-529 quality of care on basis of, 136-137, 510-521 physician perspective on, 385~01 physician voice in hospital on basis of, 176-178 primary/urgent care centers, 36-37, 175 relationship to sources of capital, 57-59 research implications of, 142-150, 190-191 types of, 4, 16 uncompensated care on basis of, 97-116, 187-188 213, 225-226, 228, 232-233, 465-467 p Parkside Medical Services Corporation, 42 Pathologists Board certification of, 131 compensation of, 166, 395, 430, 432, 454, 457 distribution by hospital ownership, 388 Patients dumping of, 104 heavy care, 110-111, 118 Medicare in nursing homes, 110, 136 outcomes, 354-376 physician attitudes toward, 14 readmission rates, 134 outcomes 133-134, 135, 354-376
INDEX post-operative mortality of, 133-134 selection by hospitals. 262-263, 265, 272-2~5, 278, 281, 284, 287 types treated after hospital acquisitions, 316-317 types treated prior to hospital acquisitions, 307- 312 uninsured data sources on, 100-101, 188 definition, 117 emergency room visits, 101 government obligation for, 115-116 legal responsibilities toward, 98 Payment fee-for-service, 1~2-153, 238, 240, 393, 429 hospital admission by sources of and ownership, 101 hospital methods for assuring, 467 Medicaid, to nursing homes, 88, 91, 95 Medicare physician acceptance of, 14 physician in-hospital visits to, 391 policies, 27, 35, 64, 65, 76, 95, 99, 183 return on equity, 50-51, 62, 65 sources for nursing homes by type of ownership, 111 systems, conflicts of interest in, 238, 240 systems, development of, 160 third-party, 13, 14, 26, 59, 75, 239-240; see also Cost-based reimbursement Pediatricians distribution by hospital ownership, 388 financial arrangements with hospitals, 395 on hospital medical stabs, 432, 442 Personnel Pool of America, 35 Pharmacies, multihospital system ownership of, 40 Physicians attitudes toward for-profit hospitals, 394, 396-398 Board certification of, 128-129, 131, 140, 390, 425, 427428, 447 449 characteristics according to hospital type, 38~387 compensation of, 174, 197-198, 238, 393-397 conflicts of interest, 15, 152, 158-159, 161, 163- 164, 197, 214, 217, 219, 237-240, 396 control of, 239, 246 dimensions of hospital relationship with, 391 direct billing by, 160 economic incentives, 152-157 entrepreneurial activities of, 15, 43-44, 151-170, 197-198, 215 equity arrangements with hospitals, 156 ethical obligations, 151-103, 215-217, 222. 229 . . evaluation of hospital quality, 130-132, 399 exit mechanisms of, 174-178, 198 fee-for-service compensation of, 151-153, 159, 165, 238, 393, 429 fee-splitting by, 238 555 fiduciayv role of 13. 14, 15-16, 159. 161-163, 177, 197-199, 209, 237 financial arrangements with hospitals, 393-396 foreign medical school graduates, 388 general/family practice, 129, 131, 202, 387, 388, 400, 426, 434, 441 hospital governance by, 405-406, 411-414 hospital management by, 406~()8 hospital ownership by, 154, 218 hospital privileges, 174, 175, 386-393, 423-425, 427-428, 435, 438-439, 4~0. incentive bonus arrangements with, 153, 15~159, 161-162, 164-167, 197-198 income, 167, 213-214, 238-239 influence in medical institutions, 171-181, 198-199. 470-471 in hospital decision making, 24, 174-179, 198, 402, 421 in nursing homes, 135, 137 internal medicine, 388, 395, 426, 434, 443 investments in health care organizations, 153-156, 159, 162-163, 197-198 involvement in for-profit hospitals, 385-401 joint ventures with hospitals, 155-156 laboratory ownership by, 156, 166 laboratory test ordering by, 158-160, 167 leasing arrangements with hospitals, 175 license suspension, 161 locational preferences of, 141-142 medical specialty, 129, 131, 426, 444 and Medicare, 14, 241 moral obligations of, 240-241 OB/GYN, 131, 388, 395 perspective on hospital ownership, 385~01 policy options regarding, 159-165 practice patterns, 385401 preferences in hospitals, 397 public trust in, 151 qualifications of for hospital staff privileges, 128 130, 131 referral and admission patterns, 173-175, 178, 179 refusal to accept patients, 212-213 relationships with health care organizations, 10-11, 15-16, 24 relicensing of, 214 responsibilities to patients, 15-16, 24 responsibility for quality, 171-174, 237-245 self-regulation, 242, 24~247 services, volume of, 14, 156, 158-159, 238 surgical specialty, 129, 131, 388, 434, 445 surplus of, 37 third-party payments to, 14 unionization of, 180 Preferred provider arrangements, 41 Presbyterian-St. Luke's Hospital (Denver), 144 Presidential Commission for the Study of Ethical
556 Problems in Medicine and Biomedical and Behavioral Research, 113, 526 Primarv/urgent care centers, 36, 37, 44 PruCare enrollees, 34 Psychiatric Institutes of America, 44 Psychiatrists, 131, 395 Q Quality Care, Inc., 35 R Radiologists Board certification of, 131 compensation of, 166, 395, 430, 431, 452, 456 distribution by hospital ownership, 388 Radiology units, multihospital system ownership of, 40 Rehab Hospital Services, 38 Rehabilitation, cardiac and physical, 38 Republic Health Care Corporation growth trends, 109-110, 250, 252, 254-256 number of hospitals, 44, 250 occupancy rates, 95 origins, 253 profit maximization strategies, 17 Research, medical Beneficiaries of, 229 effects of investor ownership on, 142-150, 142-143, 148-150, 190-191 funding for, 148 Revenues excess, 52 for depreciation and amortization expenses, 52 from sale of stock, 61 investor-owned organization sources of, 6, 20 margins for U.S. community hospitals, 99 multihospital system sources, 41 net margins, 9 nonoperating examples, 47 nonpatient sources, 76, 85, 86, 99 not-for-profit sources, 6, 93 operating, measures of, 273-277, 287 see also Hospitals, revenues Roanoke Memorial Hospital Association, 42 Ross-Loos Health Plan, 33 Social Secuntv, 494~95 Southern Medical Services, 503 St. Joseph Health System 41 Summit Care Corporation, 503 SunHealth, 10 Surgery. elective outcomes of, 355-368. 371-373 sales on 17 Surgicare, Inc., 36 INDEX Sweden, hospital ownership and financing in, 56 Svmbion, 149 T Tax Equity and Fiscal Responsibility Act, 366, 506 Taxes ACES, 54 deferred, 53-54 exemptions from, 6, 8, 66, 113-114, 227 health care subsidization with, 203 investment credits, 509 of investor-owned health care corporations, 53-54 policies relevant to nursing homes, 509-510 Tennessee, uncompensated care in, 102-103 Texas corporate practice of medicine in, 166 Medicaid utilization rate in, 528-529 nursing homes, 508, 517-520, 524-525 uncompensated care in, 102-103, 117 Tulane Hospital (New Orleans), 144 U Uncompensated care, see Health care, uncompensated Unicare, 502, 503, 509 Unifour Medical Management, 503 United Healthcare Corporation, 34 United Kingdom, hospital ownership and financing in, 56 University of Mississippi Hospital, 144 Upjohn Health Care Services, 35 U.S. Health Care Systems, 33 Vari-Care Inc., 38, 503 VHA Health Ventures, 41 VHA Management Services, 43 Virginia nursing home spending patterns, 515-516, 525 uncompensated care in, 102-103, 119, 188 Visiting Nurse Associations, number of Medicare- certified, 35 Voluntary Health Enterprises, 41, 43 Voluntary Hospitals of America classification of, 29 corporate structure of, 4243 hybridization with not-for-profit hospitals, 10 services offered by, 43 vertical integration and diversification efforts, 41 W Washington, Medicaid patients in nursing homes, 118, 528 Wesley Medical Center (Kansas), 144 West Germany, 57, 218
