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The marginal effect of bond insurance on hospital, tax-exempt bond yields.

In response to changes in the health care environment and the tax-exempt bond market, many hospitals have purchased bond insurance and other forms of credit enhancement to lower the yields on their debt financings. This study of tax-exempt revenue bonds issued by hospitals from 1982-84 estimates that bond insurance lowers yields on hospital bonds by approximately 87 basis points and that bond insurance serves as a substitute measure of creditworthiness. The findings also suggest that the insured group of hospital bonds is more homogeneous than the uninsured group in terms of characteristics that affect the risks associated with hospital investments. Insured bonds seem to represent hospitals in an intermediate risk group.

Capital Financing↗

The IRS looks closely at homes for the aging. Organizations must be prepared to face increased scrutiny on tax-exempt status and financing.

Tax-exempt status has long been perceived as appropriate for the traditional retirement home (i.e., congregate housing and life-care facility), which serves the elderly and typically experiences low profit margins. An organization that is both organized and operated exclusively for religious, charitable, scientific, literary, or educational purposes or for testing for public safety may qualify for tax-exempt status under Internal Revenue Code section 501(c)(3). The Internal Revenue Service uses the generic term "homes for the aging" to include all forms of retirement housing facilities (except nursing homes that solely provide the highest level of nursing care). A home for the aging that qualifies under section 501(c)(3) (through satisfaction of the organizational and operational tests) will qualify for charitable status for federal tax purposes if it operates to satisfy the following basic needs of aged persons: suitable housing, healthcare, and financial security. In general, not-for-profit organizations recognized as exempt under code section 501(c)(3) may be eligible for tax-exempt financing to develop a home for the aging through the issuance of tax-exempt bonds. Effective tax-exemption planning is a necessary part of the business planning process by sophisticated not-for-profit organizations that own and operate (or desire to own and operate) charitable homes for the aging and similar housing facilities serving the elderly. The benefits of exempt status remain attractive for many such organizations. The challenge of obtaining and maintaining that status is becoming far more burdensome.

Aged↗

Occupational medicine. The essentials of finance.

Finance is concerned with the generation and use of funds to support organizational objectives whereas accounting records transactions and summarizes how funds are expended. Money has costs associated with its procurement and use. There are costs associated with maintaining equipment and inventory. Financial analysts have developed methods to evaluate a company's efficiency in using money. While the occupational physician may not be directly involved in financial activities, knowledge of the techniques used should improve an understanding of organizational limitations.

Accounts Payable and Receivable↗

Certain legal aspects of derivatives.

This article discusses legal characteristics of derivatives that a not-for-profit health care company may use in a conduit financing in which a governmental issuer issues bonds for the benefit of a health care company. This article also presents the Master Agreement promulgated by the International Swaps and Derivatives Association; discusses how to get out of a derivative; discusses the status of a derivative after insolvency of a counterparty; presents disclosure issues relating to documents prepared in connection with an issue of bonds; and describes the treatment of derivatives under commodities regulations. It concludes with a presentation of possible new regulations applying to derivatives.

Bankruptcy↗

Universal access to health care: a practical perspective.

Policy disconnected from economic reality is bad policy. Neither government financed health insurance nor an employer mandated health insurance approach are in the national interest. Higher national priorities compel a reallocation of resources from consumption to investment. This need not, however, cause an abandonment of efforts to deal with the problems of the uninsured and other health reforms. Successful health care reform is achievable provided it is responsive to higher priorities for economic growth. A strong economy and the production of wealth are indispensable to economic justice. Toward this end, a program of universal access is proposed whereby families and individuals are required to pay for their own health insurance up to a fixed percentage of disposable personal income before public payments kick in. Government's chief role is to establish a standard package of cost-effective benefits to be offered by all insurance carriers, the cost of which is approximately 40 percent less than conventional insurance coverage because of the elimination of reimbursement for clinically non-efficacious and cost-ineffective services. Public financing is relegated to a residual role in which subsidies are targeted on the needy. Much of the momentum for cost control is transferred to consumers and private insurers, both of whom acquire a vested interest in obtaining value for money. Uniform rules for underwriting, eligibility, and enrollment practices guard against socially harmful practices such as experience rating and exclusion of preexisting conditions. The household responsibility and equity plan described herein could free up as much as $90 billion or more for public investment in economic growth and national debt reduction while assuring access to health care regardless of ability to pay. Economic revitalization will be assisted by changes in household savings. With health care no longer a free good and government social programs concentrated on the truly needy, individual propensity to save will increase, thereby enlarging the pool of capital for financing investments in economic growth. Putting more responsibility for health care financing on households with an ability to pay also serves to reinforce and expand the work ethic. Privatizing responsibility by severing health insurance from the workplace connection improves the geographic and occupational mobility of labor, diminishes employer tendencies to discriminate against hiring the disabled and older employees, and eliminates a major source of labor unrest.(ABSTRACT TRUNCATED AT 400 WORDS)

Community Participation↗

Room for improvement.

First announced in 1992 by the then Conservative Government, the Private Finance Initiative is a contract whereby private companies finance, design, build and manage public buildings, such as hospitals and schools, and lease them to the public sector for a set period--typically 30 years. In healthcare, the scheme has been particularly prolific, with 34 hospitals and 119 other PFI health schemes built to date. PFI projects are also expected to account for the majority of the 15 NHS hospital developments worth over pound 4 billion, that were recently announced by Health Secretary John Reid. Arguments aside, few could deny that PFI has been instrumental in facilitating the biggest NHS hospital building programme ever seen.

Building Codes↗

IRS issues guidance on tax-exempt bond requirements.

Enforcing compliance with rules governing facilities financed with tax-exempt bonds recently has become an IRS priority. Integrated delivery systems (IDSs) that include such facilities, therefore, should take steps to ensure that the private business use of those facilities does not exceed the legal threshold amount, thereby jeopardizing the tax-exempt status of the bonds. Management contracts, research agreements, and leases are arrangements with the greatest potential to result in noncompliance. Instituting a compliance program to monitor the use of bond proceeds and minimize the amount of private business use of facilities over the bond term can reduce an organization's risk of penalty.

Capital Financing↗

Characteristics of private medical practice in India: a provider perspective.

Supply factors, depicted by input market conditions and government regulations, and demand factors, depicted by financing mechanisms and utilization patterns, are likely to determine the shape and character of private medical practice. The interaction of this complex set of factors will have considerable implications for the cost access and quality of services offered by this sector. Understanding these characteristics from a provider perspective is imperative to influence the behaviour of providers in this sector. This paper describes some of the important characteristics of private medical practice using a case study of an urban district in India, Ahmedabad, and analyzes their implications. Using survey data of 130 private doctors in the allopathic system, the paper describes broad characteristics of private medical practice using parameters such as growth of private practice, patient load and referrals within the sector, payment methods and determinants, patient concerns, and risks associated with private practice. The paper presents views on the prevalence of various undesirable practices in the private medical sector. It also discusses the awareness of providers about selected important regulations. The findings suggest that growing capital intensity due to cost of location, medical equipment and technology, and financial sources of capital investments are some unfavourable environmental factors experienced by private providers. The findings also indicate a high prevalence of various undesirable practices and low awareness of the objectives of important legislation among practicing doctors. Lack of awareness of important and relevant legislation raises serious questions about the implementation of these laws. The paper identifies the strong need for instituting and implementing an effective continuing medical education programme for practicing doctors, and linking it with their registration and continuation of their license to practice. The paper also suggests that cost of health care, access and quality problems will worsen with the growth of the private sector. The public policy response to check some of the undesirable consequences of this growth is critical and should focus on strengthening the existing institutional mechanisms to protect patients, developing and implementing an appropriate regulatory framework and strengthening the public health care delivery system. The study also discusses various other policy implications arising.

Attitude of Health Personnel↗

Measuring the value of healthcare business assets.

Healthcare organizations obtain valuations of business assets for many reasons, including to support decisions regarding potential mergers, sale of business components, or financing; for tax assessments; and for defense against law-suits. If compliance with regulations may be an issue, such as when a not-for-profit organization is involved in a transaction, healthcare organizations should seek an independent appraisal to ensure that applicable legal standards are met. Whether or not regulatory issues are involved, however, an accurate and useful valuation of business assets depends on many factors. Financial managers must understand the purpose and function of the valuation, choice of appropriate valuation techniques, proper assessment of intangible value, use of realistic growth rates, appropriate emphasis on key focus areas of the valuation (e.g., risk and future income streams), and an accounting of physician compensation.

Capital Financing↗

A comparative analysis of the influence of financing on Boston's neighborhood health center dental programs in 1979 and 1985.

This study determined whether or not income and other structural components of 15 Boston neighborhood health centers in 1979 and 1985 had a systematic influence on their dental productivity as measured by dental visits. Health center revenue sources, health center costs, dental program costs, dental and medical manpower, and type of facility license were analyzed in relation to dental visits using secondary data from multiple sources. Dental costs and dental manpower were substantial predictors of dental visits for both periods of time. Stepwise regression analyses suggest that in 1979, the type of license and the type of grants received also were associated with the number of dental visits. In 1985, however, none of the revenue variables showed an association with dental visits when controlling for dental manpower and dental costs.

Boston↗

Borrowing to build: private money and public welfare.

The process of local government borrowing to finance the capital needs of social services has an impact on both central-local relations and the type of service which can be offered to the citizen-consumer. Based on an examination of these relationships in the United States, the United Kingdom, France, and Italy, it is postulated that different types of central-local relations are dependent on the nature of relations between central government and the investment community. Further, through use of material from a case study of public housing politics in Italy, it is shown how the investment criteria of the so-called "private" sector are transferred to the operations of the public sector through the mechanism of local borrowing. This transferal affects the manner in which social services are conceived and delivered.

Financial Management↗

Radiology practices and their contracts with hospitals, 1989-1990: a representative sample survey.

Because of concern about pressures from hospitals for changes in their contracts with radiology practices, the American College of Radiology undertook a stratified sample survey of radiology practices and their contracts with hospitals in late 1989 and early 1990. After three remailings, the survey obtained 904 valid responses for a 64% response rate. It found (weighting data to represent all radiology practices in the nation) that 91% of radiology practices provide services in hospitals. There are contracts at 57% of these hospital sites, and hospitals use tax-exempt bond financing in 54% of the sites with contracts. One year is the most common duration of contracts, and 90 days is the most common cancellation period (89% of contracts can be canceled during the contract's term). Eighty-six percent of contracts are exclusive; 73% are automatically renewable ("evergreen"). Separate billing exists in well over 90% of hospitals with contracts. Two percent of contracts require radiologists to provide equipment; 4% require them to provide support staff. There are fixed-fee arrangements in 9% of contracts and percent compensation arrangements in 3%. Hospitals share in radiologists' fees as a charge for contractual privileges in 5% of contracts. Twenty-seven percent of contracts require hospital approval for radiologists' fee increases; 19% require radiologists to participate with Blue Shield or Medicare. If a contract characteristic is predominant nationally, it is predominant in every region, for solo, small, medium, and large practices, and whether or not hospitals use tax-exempt bond financing. There is, however, some modest variation in frequency of contract provisions. Multivariate analysis shows that most such variation reflects true effects of region and other variables, not statistical artifacts. Region was a statistically significant determinant of 11 of 17 contract characteristics studied. Practice size was a statistically significant determinant of only about half as many characteristics. The survey found some interference in the independence of radiology practices (e.g., required hospital approval of fee increases), questionable clauses (e.g., mandated provision of equipment), and even illegal ones (hospitals charging a fee for contract privileges). Knowledge of the survey findings can make individual radiology practices more effective in negotiations with hospitals and assist the profession in forming a strategy to oppose disadvantageous and illegal provisions.

Capital Financing↗

Meeting the challenge of funding and allocating resources to mental health across Europe: developing the Mental Health Economics European Network.

AIMS: There is growing demand for economic analysis to support strategic decision-making for mental health but the availability of economic evidence, in particular on system performance remains limited. The Mental Health Economics European Network (MHEEN) was set up in 2002 with the broad objective of developing a base for mental health economics information and subsequent work in 17 countries. METHODS: Data on financing, expenditure and costs, provision of services, workforce, employment and capacity for economic evaluation were collected through bespoke questionnaires developed iteratively by the Network. This was augmented by a literature review and analysis of international databases. RESULTS: Findings on financing alone suggest that in many European countries mental health appears to be neglected while mechanisms for resource allocation are rarely linked to objective measure of population mental health needs. Numerous economic barriers and potential solutions were identified. Economic incentives may be one way of promoting change, although there is no 'one size fits all solution. CONCLUSIONS: There are significant benefits and synergies to be gained from the continuing development of networks such as MHEEN. In particular the analysis can be used to inform developments in Central and Eastern Europe. For instance there is much that can be learnt on both how the balance of care between institutional and non-institutional care has changed and on the role played by economic incentives in ensuring that resources were used to develop alternative community-based systems.

Capital Financing↗

Whose policy is it anyway? International and national influences on health policy development in Uganda.

As national resources for health decline, so dependence on international resources to finance the capital and recurrent costs is increasing. This dependence, combined with an increasing emphasis on policy-based, as opposed to project-based, lending and grant-making has been accompanied by greater involvement of international actors in the formation of national health policy. This paper explores the process of health policy development in Uganda and examines how major donors are influencing and conflicting with national policy-making bodies. Focusing on two examples of user fees and drugs policies, it argues that while the content of international prescriptions to strengthen the health system may not be bad in itself, the process by which they are applied potentially threatens national sovereignty and weakens mechanisms for ensuring accountability. It concludes by proposing that in order to increase the sustainability of policy reforms, much greater emphasis should be placed on strengthening national capacity for policy analysis and research, building up policy networks and enhancing the quality of information available to the public concerning key policy changes.

Developing Countries↗

Using financing to motivate a for-profit health care provider to deliver family planning services: is it a cost-effective intervention? A study of AAR health services in Kenya.

Despite much discussion of the role of private health care providers, there are no tried and tested models for supporting for-profit providers in ways that produce cost-effective public health outcomes. This paper examines the cost effectiveness of using a loan mechanism to motivate a for-profit provider to deliver family planning services. The intervention examined directly resulted in a private provider delivering family planning services, however, it did not create a long-term financial incentive for the private provider to promote the use of family planning. The cost effectiveness of this intervention is analysed using a methodology that captures long term sustainability of the intervention within a traditional family planning outcome measure, such as couple years protection (CYP), by discounting future expected CYPs. Depending on the method for analysing costs and assumptions regarding future CYPs, this intervention produced family planning outcomes at no or very low cost (0 dollars-4.11 dollars per CYP). The analysis demonstrates that innovative family planning interventions with private providers should be considered as they can be more cost effective than traditional programmes.

Capital Financing↗

Is a share buyback right for your company?

Contrary to popular wisdom, buybacks don't create value by raising earnings per share. But they do indeed create value, and in two very different ways. First, a buyback sends signals about the company's prospects to the market--hopefully, that prospects are so good that the best investment managers can make right now is in their own company. But investors won't see it that way if other, negative, signals are coming from the company, and it's rarely a good idea for companies in high-growth industries, where investors expect that money to be spent pursuing new opportunities. Second, when financed as a debt issue, a buyback is essentially an exchange of equity for debt, conferring the traditional benefits of leverage--a tax shield and a discipline for managers. For such a buyback to make sense, a company would need to have taxable profits in need of shielding, of course, and be able to predict its future cash flows fairly accurately. Justin Pettit has found that managers routinely underestimate how many shares they need to buy to send a credible signal to the markets, and he offers a way to calculate that number. He also goes through the iterative steps involved in working out how many shares must be purchased to reach a target level of debt. Then he takes a look at the advantages and disadvantages of the three most common ways that companies make the actual purchases--open-market purchases, fixed-price tender offers, and auction-based tender offers. When a company's performance is lagging, a share buyback can look attractive. Unfortunately, a buyback can backfire--unless executives understand why, when, and how to use this powerful and risky tool.

Capital Financing↗

Debt, investment and endowment accumulation: the case of not-for-profit hospitals.

Not-for-profit hospitals benefit from special tax rules that allow state authorities to issue tax-exempt bonds on their behalf, which may affect their investment and financing choices. Hospitals may respond by increasing their investment in physical assets; however, they may also engage in tax arbitrage by using the tax-exempt debt while maintaining endowment assets. The paper combines data from tax (information) returns and the annual survey of hospitals by the American Hospital Association for 1993-1996. Overall, the results are consistent with substantial tax planning by not-for-profit hospitals. Of the US$ 55.9 billion in tax-exempt liabilities of hospitals in 1996, as much as US$ 32.6 billion could have been eliminated if hospitals spent their endowments instead of borrowing. Furthermore, controlling for hospital size (in terms of revenues and operating assets), endowment assets are associated with a higher ratio of tax-exempt (or total) debt to operating assets. In contrast, endowment assets are not related to taxable debt suggesting that the effects of the endowment on borrowing are motivated by tax incentives. Investment and endowment accumulation regressions suggest that increases in debt increase both physical investment and endowment accumulation but these effects are concentrated among cash-rich hospitals for which the effects on endowment accumulation effects are larger than the effects on physical investment.

Accounts Payable and Receivable↗

Bootstrap finance: the art of start-ups.

Entrepreneurship is more popular than ever: courses are full, policymakers emphasize new ventures, managers yearn to go off on their own. Would-be founders often misplace their energies, however. Believing in a "big money" model of entrepreneurship, they spend a lot of time trying to attract investors instead of using wits and hustle to get their ideas off the ground. A study of 100 of the 1989 Inc. "500" list of fastest growing U.S. start-ups attests to the value of bootstrapping. In fact, what it takes to start a business often conflicts with what venture capitalists require. Investors prefer solid plans, well-defined markets, and track records. Entrepreneurs are heavy on energy and enthusiasm but may be short on credentials. They thrive in rapidly changing environments where uncertain prospects may scare off established companies. Rolling with the punches is often more important than formal plans. Striving to adhere to investors' criteria can diminish the flexibility--the try-it, fix-it approach--an entrepreneur needs to make a new venture work. Seven principles are basic for successful start-ups: get operational fast; look for quick break-even, cash-generating projects; offer high-value products or services that can sustain direct personal selling; don't try to hire the crack team; keep growth in check; focus on cash; and cultivate banks early. Growth and change are the start-up's natural environment. But change is also the reward for success: just as ventures grow, their founders usually have to take a fresh look at everything again: roles, organization, even the very policies that got the business up and running.

Capital Financing↗