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Public hospitals have long been major players in the US health care delivery system. However, many public hospitals have privatized during the past few decades. The purpose of this chapter was to investigate the impact of public hospitals' privatization on community orientation (CO). This longitudinal study used a national sample of nonfederal acute-care public hospitals (1997–2010). Negative binomial regression models with hospital-level and year fixed effects were used to estimate the relationships. Our findings suggested that privatization was associated with a 14% increase in the number of CO activities, on average, compared with the number of CO activities prior to privatization. Public hospitals privatizing to for-profit status exhibited a 29% increase in the number of CO activities, relative to an insignificant 9% increase for public hospitals privatizing to not-for-profit status.

Change in ownership among U.S. community hospitals has been frequent and, not surprisingly, remains an important issue for both researchers and public policy makers. In the past, investor-owned hospitals were long suspected of pursuing financial over other goals, culminating in several reviews that found few differences between for-profit and nonprofit forms (Gray, 1986; Sloan, 2000; Sloan, Picone, Taylor, & Chou, 2001). Nevertheless, continuing to the present day, several states prohibit investor-ownership of community hospitals. Conversions to investor-ownership are only one of six types of ownership change, however, with relatively less attention paid to the other types (e.g., for-profit to nonprofit, public to nonprofit). This study has two parts. We first review the literature on the various types of ownership conversion among community hospitals. This review includes the rate at which conversions occur over time, the relative frequency in conversions between specific ownership categories and the observed effects of conversion on hospital operations (e.g., strategic direction and decision-making processes) and performance (e.g., access, quality, and cost). Overall, we find that the impact of ownership conversion on the different measures is mixed, with slightly greater evidence for positive effects on hospital efficiency. As one explanation for these findings, we suggest that the impact of ownership conversion on hospital performance may be mediated by changes in the hospital's strategic content and process. Such a hypothesis has not been proposed or examined in the literature. To address this gap, we next study the role of strategic reorientation following hospital conversion in a field study. We conceptualize ownership conversion within a strategic adaptation framework, and then analyze the changes in strategy content and process across sixteen hospitals that have undergone ownership conversions from nonprofit to for-profit, public to for-profit, public to nonprofit, and for-profit to nonprofit. The field study findings delineate the strategic paths and processes implemented by new owners post-conversion. We find remarkable similarity in the content of strategies undertaken but differences in the process of strategic decision making associated with different types of ownership changes. We also find three main performance effects: hospitals change ownership for financial reasons, experience increases in revenues and capital investment post-conversion, and pursue labor force reductions post-conversion. Membership in a multi-hospital system, however, may be a major determinant of both strategy content and decision-making process that is confounded with ownership change. That is, ownership conversion may mask the impact of system membership on a hospital's strategic actions. These findings may explain the pattern of performance effects observed in the literature on ownership conversions.

Reexamination and reinterpretation of the process of deinstitutionalization of public mental hospital inpatients.

A comprehensive review of related research is presented and lessons learned for the sociology of mental health are identified.

The processes of both institutionalization and deinstitutionalization were motivated by belief in the influence of the social environment on the course of mental illness, but while in the early 19th century the social environment of the mental hospital was seen as therapeutic, later in the 20th century the now primarily custodial social environment of large state mental hospitals was seen as iatrogenic. Nonetheless, research in both periods indicated the benefit of socially supportive environments in the hospital, while research on programs for deinstitutionalized patients and for homeless persons indicated the value of comparable features in community programs.

While the process of deinstitutionalization is largely concluded, research should focus on identifying features of the social environment that can maximize rehabilitation.

The debate over the merits of hospital-based and community-based mental health services is misplaced; policies should instead focus on the alternatives for providing socially supportive environments. Deinstitutionalization in the absence of socially supportive programs has been associated with increased rates of homelessness and incarceration among those most chronically ill.

A comprehensive analysis of deinstitutionalization that highlights flaws in prior sociological perspectives and charts a new direction for scholarship.

The purpose of this chapter is to apply structural functional theory and the concept of “unbundling” to an analysis of the deinstitutionalization and community mental health efforts that have shaped the current mental health services environment.

We examine the original goals of the institutional movement, the arguments supporting it, and the functions of the institutions that were created. We then examine the criticisms of that approach and the success of the subsequent deinstitutionalization process, which attempted to undo this process by recreating the hospitals’ functions in community settings. Finally, we address the question of whether the critical functions of psychiatric institutions have indeed been adequately recreated.

Our overview of outcomes from this process suggests that the unbundling of state hospital functions did not yield an adequate system of care and support, and that the functions of state hospitals, including social control and incapacitation with respect to public displays of deviance were not sufficiently recreated in the community-based settings.

The arguments for the construction of state hospitals, the critiques of those settings, and the current criticism of efforts to replace their functions are eerily similar. Actors involved in the design of mental health services should take into account the functions of existing services and the gaps between them. Consideration of the history of efforts at functional change might also serve this process well.

This paper focuses on the impact of recent federal health policy on local community efforts to support the survival of rural hospitals. Rural communities in the United States have an established tradition of providing public financial support to local hospitals. The Balanced Budget Act of 1997 (BBA) expanded Medicare’s prospective payment system to non-acute care services, which promised reduced hospital reimbursement. Part of this legislation, the Critical Access Hospital (CAH) program, was specifically designed to counter the negative impact the broader legislation was expected to have. This study was designed to investigate the hypothesis that counties receiving financial relief for local hospitals through participation in the CAH program would show decreases in county subsidy levels compared to other hospitals. All 123 hospitals in Kansas were studied in 1994, well before BBA legislation, and again in 2001. Data on county-level health care spending for each of the two years were abstracted from all county budgets in Kansas. The amounts counties contributed to local hospitals were calculated and compared in terms of CAH versus non-CAH hospitals with attention to patterns of increase. Results showed that CAH hospitals, in spite of participation in the federal program, received greater local public financial support and experienced greater funding increases than other community hospitals. The implications of these findings are discussed in terms of the circumstances of rural hospitals and recent changes in the CAH program.

The Abdur Razzaque Ansari Memorial Weavers Hospital (ARAM) came into effect on 7 April 1996, and is dedicated to the people of Jharkhand and weavers. To deal with the issues of inequity in healthcare services, ARAM was founded for the extension of affordable healthcare services to the needy in and around the area of Jharkhand. Visualised by a great social worker and legend Abdur Razzaque Ansari, it has been successfully run by his eldest son Mr Sayeed Ahmad Ansari for 28 years. This research uses mainly a case-study approach through secondary data from the hospital website and other websites citing ARAM and its functions. Consent to use data for the study was obtained from Mr. Sayeed Ahmad Ansari. Primary information was collected through the patients who availed facilities from the hospital. They were interviewed through a semi-structured questionnaire each taking 30-40 minutes. Taken over by Medanta Group on 8 July 2015 (earlier being managed by Apollo Hospitals Group for 20 years), it is the first super speciality community hospital in Eastern India. Treating over 50,000 patients yearly with state-of-the-art medical equipment and providing discounts to lower-income groups, people from the weaver’s community, freedom fighters and members of ICSI have intrigued people from these sections for affordable treatment and facilities in and near Jharkhand. With a 200 bed-capacity, nine different disciplines and 12 departments spread across the city of Ranchi, the hospital caters to a massive population at a much-subsidised rate. Reaching out to rural villages through free medical camps and awareness campaigns, the hospital showcases how a successful model of healthcare cooperative can be replicated accordingly in similar developing and underdeveloped regions.

The long-term financial stability of hospital systems represents a “grand challenge” in health care. New ownership forms, such as private equity (PE), promise to achieve better financial performance than nonprofit or for-profit systems. In this study, we compare two systems with many similarities, but radically different ownership structures, missions, governance, and merger and acquisition (M&A) strategies. Both were nonprofit, religious systems serving low-income communities – Montefiore Health System and Caritas Christi Health Care.

Montefiore's M&A strategy was to invest in local hospitals and create an integrated regional system, increasing revenues by adding primary doctors and community hospitals as feeders into the system and achieving efficiencies through effective resource allocation across specialized units. Slow and steady timing of acquisitions allowed for organizational learning and balancing of debt and equity. By 2019, it owned 11 hospitals with 40,000 employees and had strong positive financials and low reliance on debt.

By contrast, in 2010, PE firm Cerberus Capital bought out Caritas (renamed Steward Health Care System) and took control of the Board of Directors, who set the system's strategic direction. Cerberus used Steward as a platform for a massive debt-driven acquisition strategy. In 2016, it sold off most of its hospitals’ property for $1.25 billion, leaving hospitals saddled with long-term inflated leases; paid itself almost $500 million in dividends; and used the rest for leveraged buyouts of 27 hospitals in 9 states in 3 years. The rapid, scattershot M&A strategy was designed to create a large corporation that could be sold off in five years for financial gain – not for health care integration. Its debt load exploded, and by 2019, its financials were deeply in the red. Its Massachusetts hospitals were the worst financial performers of any system in the state. Cerberus exited Steward in 2020 in a deal that left its physicians, the new owners, holding the debt.

This study looks at board governance in Ontario hospitals.

We conducted a research of the hospitals’ websites and a survey of board directors to study the board structure and examine governance practice in Ontario hospitals.

The findings suggest that the board structure and process in Ontario hospitals are in compliance with Accreditation Canada’s Governance Standards, and such administrative controls are appropriate. Ontario hospital boards, in general, have fulfilled their key functions of governance in terms of working as an effective board; developing a clear direction; supporting the organization to achieve its mandate; maintaining positive relationships with external stakeholders; and being accountable and achieving sustainable results. Building knowledge through information is an area where improvement is needed.

Ontario hospitals have implemented appropriate administrative controls in terms of board composition and committee structure. The results of a survey of 99 board directors from over 25 hospitals suggest that directors, in general, have a good understanding of their governance role and relationship with senior management as well as the government. The findings are also supportive of good governance practice where executives manage and nonexecutive directors monitor the performance of the executives. According to the respondents, Ontario’s hospital boards are actively involved in setting the mission, strategic goals and objectives of their organizations, and they take appropriate steps to ensure that risk management, client safety, and quality improvements are incorporated in their governance and strategic planning process. In order to discharge their fiduciary duty effectively, respondents would like to have more information from different sources. This is an area where management accounting professionals can become involved such that relevant information from a variety of sources, especially external sources, are provided to board directors for decision making.

Ontario’s hospital sector has undertaken initiatives through research and publications to promote good governance practice. Such leadership is critical to ensure that directors have the competence and skills to discharge their duties and responsibilities diligently. Hospital boards should focus on renewal while ensuring that board directors are equipped for the challenging task of governing through professional development and continuing education.

Limitations related to the use of questionnaire applies to this research study. Self-selection bias and low response rate limit the generalizability of the findings. Future research can examine the behavior of directors in the boardroom and the impact of governance variables on hospital performance, such as quality of care and patient safety.

In this chapter, we describe a multilevel, longitudinal, comparative case study approach for investigating organizational heterogeneity based on our experience studying institutional change in the health care field (Scott, Ruef, Mendel, & Caronna, 2000). By examining the relationship between organizations, populations, and fields, differences between organizations can be captured in terms of their organizational identities as well as their (changing) relationships with the organizational field. We discuss the analytical strategies we used in our study of institutional change and describe our findings of organizational heterogeneity across levels and over time. We conclude with suggestions for future research that incorporate elements of our study design and lessons from our research process and outcomes.