The Effects of Therapist Contracting on For-Profit and Not-for-Profit Medical Billing Behavior

Abstract

Within the United States, a growing debate about special tax treatment and community benefits provided by not-for-profits (NFPs) has been occurring. While the nondistribution constraint of NFPs is often thought to incentivize higher quality and more charitable care, NFPs may also be used by contractors for personal gain. This study explores whether the use of external contractors by NFP health care providers alter behavior. Using a sample of patients receiving rehabilitative care for hip fractures in skilled nursing facilities, and exploiting variation in ownership and contracting status, this study finds contracting in NFPs results in increased prevalence of profit-maximizing behaviors more commonly associated with FPs. Furthermore, contracting results in more revenue focused care delivery patterns.

Keywords

not-for-profit for-profit contracting skilled nursing facilities Medicare upcoding billing post-acute care

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References

Aaker

Vohs

Mogilner

(2010). Nonprofits are seen as warm and for-profits as competent: Firm stereotypes matter. Journal of Consumer Research, 37, 224-237.

Bowblis

J. R.

Brunt

C. S.

(2014). Medicare skilled nursing facility reimbursement and upcoding. Health Economics, 23, 821-840.

Bowblis

J. R.

Brunt

C. S.

Grabowski

D. C.

(2016). Competitive spillovers and regulatory exploitation by skilled nursing facilities. Forum for Health Economics and Policy, 19, 45-70.

Brandsen

Van de Donk

Putter

(2005). Griffins or Chameleons? Hybridity as a permanent and inevitable characteristic of the third sector. International Journal of Public Administration, 28, 749-765.

Brunt

C. S.

(2011, July). CPT fee differentials and visit upcoding under Medicare Part B. Health Economics, 20, 831-841.

Center for Medicare and Medicaid Services. (2015). What’s an assessment in skilled nursing facilities? Retrieved from http://www.medicare.gov/what-medicare-covers/part-a/assessments-in-snf.html

Dafny

Varela

(2013). Let them have choice: Gains from shifting away from employer-sponsored health insurance and toward an individual exchange. American Economic Journal: Economic Policy, 5, 32-58.

Danzon

P. M.

(1982). Hospital “profits”: The effects of reimbursement policies. Journal of Health Economics, 1, 29-52.

Drevs

Tscheulin

D. K.

Lindenmeier

(2014). Do patient perceptions vary with ownership status? A study of nonprofit, for-profit, and public hospital patients. Nonprofit and Voluntary Sector Quarterly, 43, 164-184.

10.

Frank

R. G.

Salkever

D. S.

(1994). Nonprofit organization in the health sector. The Journal of Economic Perspectives, 8, 129-144.

11.

Grabowski

D. C.

Afendulis

C. C.

McGuire

T. G.

(2011). Medicare prospective payment and the volume and intensity of skilled nursing facility services. Journal of Health Economics, 30, 675-684.

12.

Hansmann

H. B.

(1980). The role of nonprofit enterprise. Yale Law Journal, 89, 835-901.

13.

Henry

(2015). Judge calls nonprofits “legal fictions,” revokes hospital property tax exemption. Healthcare Dive. Retrieved from http://www.healthcaredive.com/news/judge-calls-nonprofits-legal-fictions-revokes-hospital-property-tax-exem/401706/

14.

Horwitz

J. R.

Nichols

(2009). Hospital ownership and medical services: Market mix, spillover effects, and nonprofit objectives. Journal of Health Economics, 28, 924-937.

15.

Liang

L.-L.

(2015). Do diagnosis-related group-based payments incentivise hospitals to adjust output mix? Health Economics, 24, 454-469.

16.

Lindrooth

R. C.

Weisbrod

B. A.

(2007). Do religious nonprofit and for-profit organizations respond differently to financial incentives? The hospice industry. Journal of Health Economics, 26, 342-357.

17.

McDavid

(2014, October). Risky business: Outsourcing SNF therapy. Retrieved from http://nancybeckley.com/risky-business-outsourcing-snf-therapy/

18.

Meiksins

(2015a). Nonprofit hospitals facing increased scrutiny. Nonprofit Quarterly. Retrieved from https://nonprofitquarterly.org////nonprofit-hospitals-facing-increased-scrutiny/

19.

Meiksins

(2015b). Unintended consequences of the Maine nonprofit property tax proposal. Nonprofit Quarterly. Retrieved from https://nonprofitquarterly.org////unintended-consequences-of-the-maine-nonprofit-property-tax-proposal/

20.

Morrisey

M. A.

Wedig

G. J.

Hassan

(1996). Do nonprofit hospitals pay their way? Health Affairs, 15, 132-144.

21.

Newhouse

J. P.

(1970). Toward a theory of nonprofit institutions: An economic model of a hospital. The American Economic Review, 60, 64-74.

22.

O’Regan

K. M.

Oster

S. M.

(2000). Nonprofit and for-profit partnerships: Rationale and challenges of cross-sector contracting. Nonprofit and Voluntary Sector Quarterly, 29, 120-140.

23.

Pauly

M. V.

(1987). Nonprofit firms in medical markets. The American Economic Review, 77, 257-262.

24.

Schlesinger

Gray

B. H.

(2006). How nonprofits matter in American medicine, and what to do about it. Health Affairs, 25, W287-W303.

25.

Silverman

Skinner

(2004). Medicare upcoding and hospital ownership. Journal of Health Economics, 23, 369-389.

26.

Skelcher

Smith

S. R.

(2015). Theorizing hybridity: Institutional logics, complex organizations, and actor identities: The case of nonprofits. Public Administration, 93, 433-448.

27.

Sloan

F. A.

(2000). Not-for-profit ownership and hospital behavior. In Cuyler

A. J.

Newhouse

J. P.

(Eds.), Handbook of health economics (Vol. 1, pp. 1141-1174). Amsterdam, The Netherlands: Elsevier.

28.

Terza

J. V.

Basu

Rathouz

P. J.

(2008). Two-stage residual inclusion estimation: Addressing endogeneity in health econometric modeling. Journal of Health Economics, 27, 531-543.

29.

U.S. v. Life Care Services, et al. (2014). Retrieved from http://www.justice.gov/opa/pr/two-companies-pay-375-million-allegedly-causing-submission-claims-unreasonable-or-unnecessary

30.

U.S. v. RehabCare, Inc., et al. (2011). Retrieved from http://www.justice.gov/sites/default/files/usao-mn/legacy/2011/12/12/RehabCareGroup%20complaint.pdf

31.

Wodchis

W. P.

(2004). Physical rehabilitation following Medicare prospective payment for skilled nursing facilities. Health Services Research, 39, 1299-1318

32.

Zinn

Mor

Intrator

Feng

Angelelli

Davis

(2003). The impact of the prospective payment system for skilled nursing services on therapy services provision: A transaction cost economics approach. Health Services Research, 38, 1467-1485.