Nonprofit conversion: Theory, evidence, and state policy options

Objective. To describe the contributions of nonprofit hospitals and health plans to healthcare markets and to analyze state policy options with regard to the conversion of nonprofits to for-profit status. Data Sources/Study Setting. Secondary national and state data from a variety of sources, 1980-present. Study Design. Policy analysis. Data Collection/Extraction Methods. Development of a conceptual economic framework; analysis of empirical, legal, and theoretical literature; and review of statutes, rules, and court decisions. Principal Findings. Three main rationales support special status for nonprofits, especially hospitals: charity care, other community benefits, and consumer protection. The main social rationale for for-profits is their incentives for better efficiency. There are reasons to expect that nonprofit and for-profit goals differ; however, measured differences in community hospital cost, prices, and quality between nonprofit and for-profit hospitals are undetectable or inconclusive. Nonprofit hospitals do provide more uncompensated care than for-profit hospitals. Similarities between nonprofit and for-profit hospitals may exist because nonprofits may set norms that for-profits follow to some degree. States have substantial power and discretion in overseeing nonprofit conversions. Some have regularized oversight through new legislation that constrains, but does not eliminate, state officials' discretion. These statutes may be deferential to converting entities and their buyers or may be very restrictive of them. Conclusions. Overseeing the appropriate disposition of nonprofit assets in individual conversions is extremely important. States should also monitor local market conditions through community benefits assessments and other data collection, however, to accurately assess (and possibly redress) what is lost or gained from conversion. Local market conditions are likely more important in determining hospital behavior than ownership form. Potentially, a mix of for-profit and nonprofit hospitals in a given market may improve market performance due to constraints the two ownership types may exercise over one another. If nonprofits disappear, the states may need to maintain quality and access norms through regulation.