For this topic, you will complete a reading providing a general overview of American hospitals, how they developed, and how they operate.

Community Hospitals: The Center of Health Care Delivery in the United States

Over the last century, hospitals have incrementally become the center of health care delivery in the United States.  And in the coming decades, what have historically been hospital organizations are likely to continue to play a central role in the full spectrum of health services (beyond just inpatient hospital care) as they anchor integrated delivery systems and networks.  The reading below provides an overview of some key concepts related to the historical development and operations of American hospitals.

General Overview of American Hospitals

According to the American Hospital Association’s (AHA) survey of hospitals, in FY 2020 there were 6,093 hospitals, with 5,139 or 84% being community hospitals (AHAa, 2022).  The AHA defines “community hospitals” as follows:

all nonfederal, short-term general, and other special hospitals. Other special hospitals include obstetrics and gynecology; eye, ear, nose, and throat; long term acute-care; rehabilitation; orthopedic; and other individually described specialty services. Community hospitals include academic medical centers or other teaching hospitals if they are nonfederal short-term hospitals.  Excluded are hospitals not accessible by the general public, such as prison hospitals or college infirmaries (AHAa, 2022).

The remaining hospitals are non-federal psychiatric hospitals, federal hospitals, or other types.  Federal hospitals include hospitals owned and operated by any federal agency, including military hospitals, Veteran’s Administration hospitals, and federal Indian Health Services hospitals. “Other” hospitals “include nonfederal long-term care hospitals and hospital units within prisons or colleges that not open to the public in general” (see Table 1 below).

Table 1

U.S. Hospitals by Type- FY2020

Source: American Hospital Association. Fast Facts on U.S. Hospitals, 2022. https://www.aha.org/statistics/fast-facts-us-hospitals

The following discussion will focus primarily on community hospitals. Among the hospitals within the broad category of “community hospitals,” there are a number of other subcategories, based on ownership type, location, and population served.  The following tables illustrate that most community hospitals:

• are private (non-government) non-profit (58%) in terms of ownership
• are affiliated with a hospital system (68%), and
• are located in urban areas (65%)

Table 2

U.S. Community Hospitals by Ownership Type- FY2020

Source: American Hospital Association. Fast Facts on U.S. Hospitals, 2022. https://www.aha.org/statistics/fast-facts-us-hospitals

Table 3

System-affiliated vs. Independent Community Hospitals .- FY2020

Source: American Hospital Association. Fast Facts on U.S. Hospitals, 2022. https://www.aha.org/statistics/fast-facts-us-hospitals

Table 4

Urban vs. Rural Location of Community Hospitals – FY2020

Source: American Hospital Association. Fast Facts on U.S. Hospitals, 2022. https://www.aha.org/statistics/fast-facts-us-hospitals

Medicare Policies Impacting Community Hospitals

Medicare and Medicaid account for approximately 60 percent of all care paid for by hospitals (AHAb, 2022), and the vast majority of full-service community hospitals participate in the Medicare and Medicaid programs.  Although Medicare and Medicaid typically reimburse at lower rates than private insurers for specific services, there is such a high volume of care provided to Medicare and Medicaid patients that most hospitals would likely go out of business if they were not able to treat these patients.  Accordingly, policies set by the Center for Medicare and Medicaid Services (CMS)–the federal agency that oversees the Medicare program–play an important role in hospital administration.

Different Categories Impacting Medicare Payment

There are several additional subcategories of community hospitals to be aware of based on how they are reimbursed (paid) for services provided to patients covered by Medicare and Medicaid:

• Acute Care Hospitals: CMS defines acute care hospitals as “A hospital that provides inpatient medical care and other related services for surgery, acute medical conditions or injuries (usually for a short-term illness or condition)” (CMS Data Navigator Glossary).  Acute care hospitals are hospitals with more than 25 beds that are typically located in populated suburban and urban areas.  They are paid by Medicare using the prospective payment system (PPS) based on diagnosis-related groups (DRGs).
• Critical Access Hospitals: CMS provides the following definition: “A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.”  (CMS Glossary).  Critical Access Hospitals (CAHs) qualify to be reimbursed by the Medicare program on a cost-plus reimbursement system, rather than the prospective diagnosis-related group (DRG) system that applies to larger acute care hospitals in more populated areas.  Qualifying for cost-plus reimbursement allows CAHs to be financially viable even while operating in sparsely populated rural areas.  CAHs play a particularly important role in highly rural states, like Idaho. In Idaho, there are 27 CAHs located in underserved rural areas (See Idaho Department of Health & Welfare Map).
• Disproportionate Share Hospital: CMS provides the following definition of a disproportionate share hospital: “A hospital with a disproportionately large share of low-income patients. Under Medicaid, States augment payment to these hospitals. Medicare inpatient hospital payments are also adjusted for this added burden.” (CMS Glossary).  This term is somewhat synonymous with “safety net” hospitals, in that these hospitals focus primarily on addressing the needs of low-income, underserved populations.  Disproportionate share hospitals may be either acute care hospitals (more than 25 staffed beds) or critical access hospitals (25 or fewer beds in an underserved rural area).

The Emergency Medical Treatment and Active Labor Act (EMTALA)

Additionally, all hospitals that participate in the Medicare program and operate an emergency department are subject to the Emergency Medical Treatment and Active Labor Act (EMTALA).  Corbett (2015) summarizes EMTALA as follows

In 1986, Congress enacted EMTALA in response to a growing problem with “patient dumping.” Prior to that time, there was no uniform statutory or common law requirement for hospitals to treat anyone. As a result, it was not unusual for hospitals to “dump” patients who presented at the emergency room with no ability to pay by simply refusing to treat them or by transferring them elsewhere. This problem appeared to worsen following implementation of the Medicare Prospective Payment System in 1983. In response, Congress sought to take steps to protect “traditional community responsibilities” and “historic standards.” EMTALA requires those hospitals that have an emergency room and also participate in Medicare2 to provide for “appropriate medical screening” of all persons (regardless of their payment status) who present for examination or treatment of a medical condition, in order to “determine whether a medical emergency” exists. If an emergency medical condition is found, the hospital must provide such further examination and treatment as necessary to stabilize the condition prior to discharging or transferring the patient to an appropriate, alternate facility.

That is not to say, however, that this treatment is provided for free or that the patient does not remain financially responsible for the costs of the services they receive. Thus, while EMTALA ensures that patients having medical emergencies will not “die on the doorsteps of the hospital,” it does not shield them from some of the harsh collection efforts previously described or prevent them from being forced into bankruptcy over unpaid medical bills (Corbett, 2015, pp. 140-141; internal citations omitted).

Medicare Quality Reporting Requirements

Hospitals that participate in Medicare are required to report data related to quality to CMS, and are penalized with a reduction in the rates Medicare will pay the hospital if they fail to provide the required data.  Below is an explanation from CMS of these quality reporting requirements and how they are used to provide information to patients through the Care Compare System (previously known as Hospital Care):

The Centers for Medicare & Medicaid Services (CMS) and the nation’s hospitals work collaboratively to publicly report hospital quality performance information on Care Compare website located at www.medicare.gov/care-compare/ and the Provider Data Catalog on data.cms.gov.

Care Compare displays hospital performance data in a consistent, unified manner to ensure the availability of credible information about the care delivered in the nation’s hospitals. Most of the participants are short-term acute care hospitals that will receive a reduction to the annual update of their Medicare fee-for-service payment rate if they do not participate by submitting data or meet other requirements of the Hospital Inpatient Quality Reporting (IQR) Program. The Hospital IQR Program was established by Section 501(b) of the Medicare Modernization Act of 2003 and extended and expanded by Section 5001(a) of the Deficit Reduction Act of 2005.

Care Compare currently provides quality measure information on:

• • Process of care measures are measures that show whether or not a health care provider gives recommended care based on guidelines, standards of care or practice parameters; that is, the treatment known to give the best results for most patients with a particular condition. These measures convert patient medical record information into percentages and/or rates of performance. Providing this information allows consumers to compare the performance of a health care provider to other providers in their state and the nation.
  • Outcome measures are measures designed to reflect the results of care, rather than whether or not a specific treatment or intervention was performed.
  • Patient experience of care is measured by a national, standardized survey of hospital patients about their experiences during a recent inpatient hospital stay. This is also referred to as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems).

History of Hospital Public Reporting

CMS first publicly reported data on hospital quality measures on a web site called Hospital Compare. Hospital Compare was created through the efforts of Medicare and the Hospital Quality Alliance (HQA). The HQA: Improving Care Through Information, a public-private collaboration, was created in December 2002 to promote reporting on hospital quality of care. The HQA consisted of organizations that represented consumers, hospitals, providers, employers, accrediting organizations, and federal agencies. The HQA effort was intended to make it easier for consumers to make informed health care decisions and to support efforts to improve quality in U.S. hospitals. Since it’s inception, many new measures and topics have been displayed in the site.

• • 2005: Ten measure “starter set” (PDF) of process of care measures were displayed on such topics as heart attack, heart failure, pneumonia and surgical care.
  • 2008: Data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, also known as the CAHPS Hospital Survey, was added to Hospital Compare. HCAHPS provides a standardized instrument and data collection methodology for measuring patient’s perspectives on hospital care. Also in 2008, CMS began reporting data on hospital 30-day mortality for heart attack, heart failure, and pneumonia.
  • 2009: CMS added data on hospital outpatient facilities, which included outpatient imaging efficiency data as well as emergency department and surgical process of care measures.
  • 2010: Addition of 30-day readmission measures for heart attack, heart failure and pneumonia patients.
  • 2011: CMS began posting data on Hospital Associated Infections (HAIs) received from the Centers for Disease Control and Preventions (CDC) National Healthcare Safety Network (NHNS). The measure sets have been expanded to include ICU’s and other hospital wards.
  • 2012: Added data from the Hospital Readmissions Reduction Program.
  • 2013: Added the Hospital Value Based Purchasing program data.
  • 2015: CMS added HCAHPS Star Ratings to the Hospital Compare website as part of the initiative to add 5-star quality ratings to its Compare websites.
  • 2016: Addition of the Overall Hospital Quality Star Rating in July 2016 and the re-introduction of measure data from Veterans Health Administration Hospitals.
  • 2017: Data on Department of Defense hospitals added to Hospital Compare.
  • 2020: Hospital Compare is consolidated with the other CMS “Compare” sites on Care Compare website located at www.medicare.gov/care-compare/ and the Provider Data Catalog
  • on data.cms.gov. The legacy Hospital Compare website is retired.

Today, CMS reports over 150 hospital quality measures on Care Compare and the Provider Data Catalog. We look forward to continuous improvement of the website, and working with stakeholders to achieve this goal. (CMS, 2021)

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Implications of Different Ownership Types

As noted above, 58% of community hospitals are private nonprofits and 24% are private for-profit. Corbett (2015) explains as follows  how nonprofit and for-profit hospitals differ in terms of organization, structure, and mission:

Organizationally, the principal features distinguishing for-profit from nonprofit hospitals can be summarized as follows. For-profit hospitals: are owned by stockholders, are managed by a stockholder-elected board of directors, raise capital by issuing taxable debt and/or selling equity, and either distribute their net earnings as stockholder dividends or reinvest it to increase stock value.12 By contrast, nonprofit hospitals: are not “owned” in the traditional sense,13 are managed by either a membership-selected or self-perpetuating (usually unpaid volunteer) board of directors, raise capital through charitable donations and/or the issuance of tax-exempt debt (assuming they have obtained tax-exempt status), and necessarily retain and reinvest all net earnings (termed the “nondistribution constraint”).14 (Corbett, 2015, pp. 108-109)

Because this is the predominant organization type among American hospitals, it’s worth taking a closer look at the “community benefit” requirement for nonprofit hospitals and the historical development of these types of hospitals.

Community-benefit requirements for tax-exempt non-profit hospitals

As non-profit organizations, non-profit hospitals may obtain tax-exempt status from federal and state/local tax authorities.  This means that nonprofit hospitals are exempt from paying income and property taxes.  In order to justify their tax-exempt status, nonprofit hospitals are required to provide some forms of “community benefit.”

Historically, this community benefit was primarily in the form of providing uncompensated “charity care” to patients who were uninsured and did not have the financial means to pay for their care out-of-pocket.  However,  following the creation of Medicare and Medicaid programs in 1965, the demand for uncompensated charity care dropped precipitously as many older and low-income individuals became covered by these federal programs.  As a result, the IRS ruled that nonprofit hospitals could qualify as charitable, tax-exempt organizations by providing other types of “community benefit” beyond just providing uncompensated care (Cobertt, 2015, p. 113-114).

Following the implementation of key coverage provisions of the enactment of the Affordable Care Act in 2014, the percentage of uninsured individuals in the U.S. has further dropped.  So in the last decade, there has been a renewed focus on the role of nonprofit hospitals in providing other types of community benefit beyond just providing uncompensated charity care.  Common types of community benefit activities include:

• Wellness, prevention, and community health education programs and events
• Issuing grants to or sponsoring community organizations
• Accepting patients covered by public programs (Medicaid, Medicare) that reimburse at lower rates than private insurance
• Maintaining hospital departments that operate at a loss, but are necessary to serve community health needs
• Facilitating educational opportunities (e.g., preceptorships, internships, residencies, etc.) to train future health professionals

Additionally, the Affordable Care Act added several new requirements for nonprofit hospitals related to community benefit.  The first (and arguably most important) of these, is the Community Health Needs Assessment (CHNA) requirement. Clausen and Hendricks (2016) explain this requirement as follows:

Every three years, a charitable hospital is now required to perform a health needs assessment focused on the community it resides in. Health needs can include expansive categories, such as social, behavioral, and environmental factors, in addition to basic needs such as addressing financial barriers to accessing care. At the conclusion of the assessment, the hospital must produce a written report of the findings for adoption by an authorized body. …  Though the focal point of the final CHNA report is a full description of the identified significant health needs of the community, the report must also include a description of how the report was created, how the facility defined community, and how the hospital took input from persons who represent “broad interests” in the community. (Clausen & Hendricks, 2016).

For examples of recent CHNAs for private, non-profit hospitals in the Boise, Idaho area, please click on the links below:

• Saint Alphonsus Health System CHNAs
• St. Luke’s Health System CHNAs

Historical factors contributing to the development of nonprofit hospitals

As noted above, 58% of all community hospitals are private nonprofits in the United States.  Corbett (2015) explains as follows regarding the factors that have contributed to this category of ownership being the predominant type in the United States:

It has been said that the modern U.S. nonprofit, tax-exempt hospital resulted from a “historical anomaly.” That is, hospitals began as donation-supported “alms houses” where volunteers engaged in a purely welfare function – providing refuge for the very sick and dying poor who had no money to have physicians treat them at home. In 1880, hospitals even prohibited physicians from charging fees to hospitalized patients. Most of these early hospitals were nonprofit by virtue of their religious affiliation. During this time, hospitals and physicians coexisted, largely independently, with hospitals supported by donations and government subsidies and physicians supported by fees from patients with means.

This began to change near the end of the nineteenth century, when medical advances increasingly transformed the hospital into a primary treatment setting for the very ill that depended upon the financial support of fee-paying patients. Many of the distinctions that previously existed between hospitals and physicians now came to distinguish for-profit from nonprofit hospitals That is, for-profit hospitals typically were operated by one or more physicians and served wealthier fee-paying patients; the generally larger nonprofit hospitals continued to rely mostly on philanthropic support, but increasingly came to depend on patient fees to meet the rising costs of their operations. By 1900, 60% of all operating hospitals were for-profit, most privately owned by one physician. By 1922, patient fees accounted for 65.2% of all hospital revenue, public appropriations for 17.7%, endowments for 3.6%, and donations for 5.7%.

The period from 1900 to the the1950s, however, saw significant growth in the number of nonprofit hospitals as both medical treatment and medical training became more complex, formalized, standardized, and institutionalized. The resulting financial pressures favored religiously affiliated nonprofits, with their ability to offer donors tax deductions and informal exemption from increasing government oversight. This in turn brought about a convergence of interests between nonprofit hospitals and physicians: by rejecting the for-profit hospital model, physicians lessened the likelihood of corporate control over their authority, improved their ability to control access to the medical profession, and generally enhanced the financial returns from their individual practices. As a result, the number of privately owned, for-profit hospitals decreased and the number of tax-exempt, nonprofit hospitals grew. The 1946 Hospital Survey and Construction Act (the Hill-Burton Act) furthered this trend for the next two decades (Corbett, 2015, pp. 109-110, internal citations omitted).

System-Affiliation vs. Independent Community Hospitals

As noted above, over two-thirds of community hospitals are now part of systems, with only one-third of hospitals remaining independent. And since the enactment of the Affordable Care Act in 2010, this trend toward greater integration has increased as hospitals form accountable care organizations (ACOs) and otherwise adopt value-based, population-health-focused models of care.

Over much of the last half-century, however, there have been a variety of financial and regulatory factors that have contributed to hospitals becoming part of larger systems or networks in order to survive.  These pressures have also impacted the relationship between hospitals and physicians practicing in hospitals.  Hamscho (2019) summarizes some of these pressures in the excerpts below.

Cost Control Pressures

As hospitals gained greater responsibility over quality of care, greater pressure to contain health care costs ensued. Throughout most of the twentieth century, hospitals and physicians were paid a fee for each service they provided. Patients paid out-of-pocket for the services they received. However, a new system of third-party payment emerged with the rise of health insurance coverage and the creation of Medicare. Health insurers and Medicare paid hospitals and physicians based on the cost of each service provided and the prevailing fee in their geographic area. These payment mechanisms insulated hospitals and physicians from the cost of medical care and created incentives to maximize the volume of services to receive higher payments.

The 1970s opened with a crisis in health care.55 By 1980, health care expenditures had reached $230 billion, up from $69 billion in 1970. As pressure to contain health care expenditures increased, third-party payers began to experiment with payment methods that moved away from the traditional fee-for-service system. In 1983, Medicare adopted the diagnosis-related group (DRG) payment system for hospitals, under which hospitals received a fixed amount per patient based on the patient’s diagnosis rather than an amount based on the actual treatment costs incurred. Other payers, including states and self-insured employers, began to steer patients into Health Maintenance Organizations (HMOs), which functioned as an alternative to health insurance plans. Like the DRG system, HMOs provided patient care for a fixed per capita fee. (Hamscho, 2019, pp. 8-9; internal citations ommitted).

Impact of managed care on physician-hospital relationships

Managed care drastically changed the nature of the relationship between physicians and hospitals by bringing changes in both reimbursement and contracting for hospital services. Throughout most of the twentieth century, the economic incentives of physicians and hospitals were aligned and higher reimbursements were associated with providing more services. Prospective payment mechanisms altered this relationship. Because hospitals were paid a fixed sum per patient, administrators were no longer indifferent to resources physicians expended in treatment. Physicians were incentivized to provide more services to receive higher payment.

At the same time, managed care brought changes in contracting for hospital services. Because HMOs provided care on a capitated basis, HMOs selectively contracted with hospitals to negotiate lower prices and shift payment risk to hospitals. Hospitals faced pressure to lower costs and gain bargaining power to improve their competitive position for managed care contracts. In response, hospitals sought more strategic relationships with physicians by acquiring physician practices, including primary care physicians, and employing the physicians. By 1998, more than 66 percent of hospitals were integrated with a physician practice, up from 33 percent in 1993.

Physician integration with employed physicians was intended to help hospitals lower costs and gain bargaining power. The expectation was that employed physicians would be more cooperative with hospital administration to manage costs and secure more hospital admissions. Moreover, employing physicians allowed hospitals to negotiate jointly with HMOs. Due to the risk that failure to reach an agreement would result in the loss of both the hospitals and physicians, employing physicians helped hospitals gain bargaining power. For physicians, hospital employment provided a “shelter from an increasingly complex and unstable market.” (Hamscho, 2019, pp. 10-11; internal citations omitted).

Licensure, Certification, Accreditation, and Deemed Status

In order for a community hospital to be permitted to operate and treat patients, there are four important concepts to understand: (1) licensure, (2) certification, (3) accreditation, and (4) deemed status.

1. 1. Licensure: This refers to the requirement that all hospitals must be licensed by the appropriate state governmental agency (in Idaho, the Idaho Department of Health & Welfare).
   2. Certification: This refers to the requirement a hospital must be certified by the Center for Medicare and Medicaid Services (CMS) in order to be able to participate in the Medicare and Medicaid programs.  Without being certified, a hospital would not be able to bill the Medicare and Medicaid programs for treating patients.  The vast majority of full-service community hospitals participate in the Medicare and Medicaid programs.
   3. Accreditation:  Accreditation is a voluntary process provided by a private, non-profit accrediting body.  The most common hospital accrediting body is the Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and before that as the Joint Commission on Accreditation of Hospitals (JCAH)).  Accreditation by the Joint Commission requires that a hospital be organized and operate according to specific standards and undergo periodic site visits/reviews overseen by the Joint Commission. For hospital administrators, Joint Commission site visits and audits can be very stressful.
   4. Deemed Status:  If a hospital is fully accredited by the Joint Commission or another qualified accrediting body, the hospital is “deemed” to have met the requirements for state licensure and CMS certification.  Accordingly, a Joint Commission accredited hospital only needs to provide state licensing officials and CMS with evidence confirming their accredited status to renew their license and certification.  Having deemed status thereby streamlines the administrative burden on hospitals by preventing the need for redundant applications and reviews to obtain state licensure and CMS certification separately.

Because of how they developed historically, and due to the benefits of deemed status, the vast majority of hospitals in the United States are accredited by the Joint Commission. As such, Joint Commission standards play a significant role in the overall structure and operations of American hospitals.  Peters & Nagele (2010) further explain the impact that Joint Commission accreditation standards have on the organization of American hospitals:

Through its Medical Staff Standards, [the Joint Comission] has dictated the organizational governance structure of hospitals it accredits in the United States for the past six decades. Eighty-eight percent (88%) of the nation’s hospitals are currently [Joint Commission]-accredited  There are only two competing hospital accreditation programs — the National Integrated Accreditation for Healthcare Organizations developed by DNV Healthcare, Inc. (“DNV”) and the Healthcare Facilities Accreditation Program of the American Osteopathic Association (“AOA”), each of which only has a tiny percentage of the market, as compared with [the Joint Commission]. [The Joint Commission’s] near-universal accreditation program gives it virtually complete mandating authority over the governance structure and operational function of American hospitals. (Peters & Nagele, 2010, p. 321)

Hamasho (2019) summarizes the historical development of Joint Commissions accreditation standards, how they parallel state licensure and CMS certification requirements, and how they have been used to improve the quality of hospital care:

In 1917, the American College of Surgeons (ACS) developed minimum standards for hospitals and a Hospital Standardization Program (HSP) to monitor compliance. These standards were meant to organize hospital facilities and clarify the roles of hospitals and physicians in maintaining quality of care. The HSP was the predecessor of the Joint Commission on Accreditation of Hospitals (JCAH).

Adherence to the ACS standards was voluntary and compliance was widely resisted. However, compliance with these standards became a requirement for participation in private and public licensing, certification, and financing programs.  States modeled their licensure statutes after the ACS standards and backed them with enforcement authority. The Medicare program relied on the ACS standards to certify hospitals for participation in the program. In addition, some health plans required compliance with the standards as a condition of participation.

The ACS standards solidified the modern organizational structure of a hospital consisting of the governing body, administrative staff, and medical staff. The standards provided for the self-regulation of physicians through an organized medical staff charged with adopting, with the consent of the hospital’s governing body, medical staff bylaws. The bylaws set the organization of the medical staff, defined its relationship with the hospital, and delineated the procedures by which staff privileges would be granted and corrective actions taken against physicians. (Hamasho, 2019, p. 4; internal citations omitted).

References

American Hospital Association (AHAa). (2022) Fast Facts on U.S. Hospitals, 2022. https://www.aha.org/statistics/fast-facts-us-hospitals

American Hospital Association (AHAb). (Feb. 2022) Fact Sheet: Underpayment by Medicare and Medicaid. https://www.aha.org/fact-sheets/2020-01-07-fact-sheet-underpayment-medicare-and-medicaid.

Center for Medicare and Medicaid Services (Dec. 1, 2021). Hospital Compare Overview. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalCompare

Clausen, E.A. & Hendricks, A. L. (2016). Cultivating the benefit of §501(r)(3): §501(r)(3) requirements for nonprofit Hospitals, 20 Lewis & Clark L. Rev. 1025.

Corbett, T. L. (2015). Healthcare corporate structure and the ACA: A need for mission primacy through a new organizational paradigm?12 Ind. Health L. Rev. 103.

Hamascho, V. (2019). Reassessing the physician-hospital relationship.13 Health L. & Pol’y Brief 1.

Peters, B.M. & Nagele, R.L. (2010). Promoting quality and patient safety: The case for abandoning the Joint Commission’s “self-governing” medical staff paradigm. 14 Mich. St. U. J. Med & L. 313.