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A Historical Look-Back to the Future?


By Wayne Firebaugh CPA, CFP® CMP™


Dr. Malcolm T. MacEachern, Director of Hospital Activities for the American College of Surgeons, presciently observed that:

… our hospitals are now involved in the worst financial crisis they have ever experienced. It is absolutely necessary to all of us to put our heads together and try to find some solution. If we are to have effective results we must have concerted and coordinated immediate action. … Repeated adjustments of expenses to income have been made. Never before has there been such a careful analysis of hospital accounting and study of financial policies. It is entirely possible for us to inaugurate improvements in business methods which will lead to greater ways and means of financing hospitals in the future. … It is true that all hospitals have already trimmed their sales to better meet the financial conditions of their respective communities. This has been chiefly through economies of administration. There has been more or less universal reduction in personnel and salaries; many economies have been effected. Everything possible has been done to reduce expenditures but this has not been sufficient to bring about immediate relief in the majority of instances. The continuance of the present economic conditions will force hospitals generally to further action. The time has come when this problem must be given even greater thought, both from its community and from its national aspect. [1]

In Agreement

Many health administration and endowment managers would agree that Dr. MacEachern accurately describes today’s healthcare funding environment. Although they might be startled to learn that Dr. MacEachern made these observations in 1932, there is the old truism that there is nothing new under the sun.


More current healthcare statistics after the November 7th 2012 presidential election and Patient Protection-Affordable Care Act confirmation, suggest that the financial crises are much the same for today’s hospitals as they were for hospitals during the Great Depression.  The American Hospital Association (AHA) recently reported a number of gloomy statistics for hospitals: [2]

  • Hospitals provided $39 billion in uncompensated care to patients in 2010 representing 5.8% of their expenses.
  • Technology costs are soaring as traditional technologies such as X-Ray machines, for $175,000, are being replaced by contemporary technologies such as CAT Scanners at $1 million, that are in turn being replaced by CT Functional Imaging with PET Scans costing $2.3 million. Even such a “simple” instrument as a scalpel that costs $20, is being replaced by equipment for electrocautery costing $12,000, that is then being replaced by harmonic scalpels costing $30,000.

More Metrics

A further review added more daunting numbers: [3]

  • In 2010, 22.4% of hospitals reported a negative total margin.
  • From 1997 through 2009, hospitals saw a small net surplus from government payments from sources such as Medicare and Medicaid deteriorate into a deficit approaching $35 billion.
  • Emergency departments in 47% of all hospitals report operating at, or over, capacity partially reflecting an approximate 10% decline in the number of emergency departments since 1991.
  • The average age of hospital plants has increased 22.5% from 8.0 years to 9.8 years in just fifteen years.
  • From 2003 through September 2007, hospital bond downgrades have outpaced hospital bond upgrades by 19%.

In a time when so much seems different yet so much seems the same, hospitals are increasingly viewing their endowments as a source of help. But what is an endowment?

Latin Roots

The same Latin words that give rise to the word “dowry” also give rise to the word endowment.[4] Interestingly, the concepts of a dowry and an endowment are in many ways similar. Both are typically viewed as gifts for continuing support or maintenance.

With respect to the healthcare entity, an endowment is generally used to smooth variations in operating results and to fund extra programs or plant purchases. Any entity that enjoys the support of an endowment also encounters the conflicting objectives between current income and future growth.



Dean William Inge, a 19th century cleric and author, aptly noted that: “Worry is interest paid on trouble before it is due.”

When managing an endowment, it is important that the institution focus its attention on those items that it can control rather than worrying about those it cannot control. Successful endowment managers seem to agree that there are at least two major areas subject to the endowment’s control: asset allocation (also known as investment policy) and payout policy.



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[1]   MacEachern, M.T., MD. “Some Economic Problems Affecting Hospitals Today and Suggestions for Their Solution.” The Bulletin of the American Hospital Association. July 1932.

[2]   Steinberg, C. Overview of the U.S. Healthcare System.  American Hospital Association (2003). Carline Steinburg is Vice President, Health Trends Analysis, for AHA.

[3]   “Trends Affecting Hospitals and Health Systems.”  TrendWatch Chartbook 2010.  American Hospital Association (2010).

[4]   Merriam-Webster Online.

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7 Responses

  1. UPDATE:

    Top 5 Most Expensive Conditions Treated in US Hospitals.


    Nurse Betty


  2. Hospital Operating Efficiency Under Healthcare Reform

    Similar to identified trends regarding healthcare quality, the concerns related to the operational efficiency, or inefficiency, of hospitals have continued to be issues of paramount importance during the transition from a fee-for-service to a pay-for-performance reimbursement program.


    A 2011 Health Affairs article estimated that hospitals that could optimize efficiency and increase average occupancy, from an average of 65% to 80% or 90%, in lieu of adding additional beds, saving up to $1 million per bed. In an era of healthcare delivery where compensation and the bottom line can drive referrals; interventions; personnel investment; and, patient satisfaction, such tactics may become necessary to drive healthcare toward adopting streamlined and operationally efficient processes that other industries have endorsed for decades.

    Robert James Cimasi MHA AVA ASA CMP™
    via Ann Miller RN MHA


  3. Going deep on hospital closures and their human impact

    Lillian Thomas of the Pittsburgh Post-Gazette wanted to know how common it was for hospital corporations to abandon disadvantaged towns and inner cities.


    That was the beginning of a reporting journey that has produced a hard-hitting, ongoing series by Thomas and colleagues at the Post-Gazette and Milwaukee Journal Sentinel.

    Hope R. Hetico RN MHA


  4. Hospitals Ask Patients to Pay Upfront

    Hospitals are increasingly asking patients to pay for procedures either upfront or before they are discharged. That’s because Americans are shouldering a greater portion of their healthcare bills, and medical centers don’t want to get stuck with patients that can’t pay. Traditionally, neither patients nor providers knew the exact price of procedures until after the insurer processed the charges. Now, however, new technology is allowing hospitals to determine the patient’s responsibility in advance of treatment.

    Starting the cost conversation early is especially important now because patients are facing higher deductibles and larger payments for services. Some are surprised to find out that they have to fork over thousands of dollars before their insurance even kicks in, hospital administrators said. The policies available on the Obamacare exchanges are hastening this trend. Many enrollees are opting for the bronze and silver plans, which often carry deductibles upwards of $5,000 and $2,000, respectively.

    Source: Tami Luhby, CNN.com [9/29/14]


  5. More People Using Non-hospital Health Services, U.S. Census Bureau Reports

    People are getting more non-hospital health services these days, the U.S. Census Bureau reports. New figures from the bureau’s economic census show that receipts at the nation’s 582,733 ambulatory healthcare facilities totaled $825.7 billion in 2012, up 23.5 percent from 2007. Employment in the industry was up 15.1 percent to 6.6 million, with a 24.3 percent increase in payroll to $341.4 billion.

    Receipts for practitioners such as chiropractors, non-physician mental health offices, podiatrists, optometrists, physical and occupational therapists, and audiologists were up 34.2 percent to $67.5 billion in 2012.

    Source: Steve Jordon
    Omaha World-Herald [11/24/14]


  6. Zack Budryk: 5 tips for hospitals in a consumer-driven market

    1. Disclose price and quality information to consumers- Only 25 percent of healthcare consumers obtain cost estimates from their providers
    2. Participate in health plan selection- Hospitals should examine whether or not they are actively communicating with consumers
    3. Work with local policies and regulations- Hospitals should assess how well laws align with their strategies as an organization
    4. Assess value and branding- Hospitals must remember the importance of being a trusted community institution
    5. Look at network contracting- Hospitals that aren’t already preferred providers within health plan networks should determine what they must do to be included

    Source: American Hospital Association


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