 My name is Kelsey Berry and I'm faculty here at the Center for Bioethics and in the Department of Global Health and Social Medicine at Harvard Medical School. And it's a big pleasure for me and my co-chair Charlotte Harrison to welcome you today to the Organizational Ethics Consortium. We've got a somewhat provocative topic for you on the topic of non-profit hospitals and trust, which is very relevant for a lot of us. I know who might be affiliated with or working in non-profit healthcare systems and more broadly as we just think about the role of nonprofits in this broader healthcare landscape. So on the next slide, I'll remind you that this is a monthly consortium. Allie, if you could advance the slide. Wonderful. We were all just commenting how we become Zoom experts at this point and yet inevitably we're always chasing our tails on something. So thank you so much, Allie and Kyle. Like I said, this is a monthly consortium that we run during the academic year. And what we try to do here is bring together scholars and practitioners in the health sector who are grappling with controversial issues that arise for health systems and organizations and look at how to align their policy and practice with some form of the right and the good. And that includes public good, of course, as is the case with what we'll be thinking about today. And our aim in this consortium really is to engage you all in considering evidence and ideas and models for health systems to ground their work in ethical values, which we know is often easier said than done, especially when considering market realities, resource limitations, and just the diversity of moral views and society about what we all ought to be doing. So this is a number one of a number of many different public consortia that the Center at Harvard Medical School runs. And as you can see, this is the last public consortium of the academic year. So we welcome you back to all of the consortia series that the Center for Biotics hosts this coming fall. I also encourage you, if you're keen on attending them to sign up for the Center newsletter, which will start to share details and registration information for these consortia when we start the season again in fall 2023. So on the next slide, I'll just share a little bit about how we can participate today. We're going to set up in a meeting format as you can tell to support a more robust conversation than a webinar would otherwise offer. And so we hope that those who are comfortable will actually go ahead and turn on your videos. And we do welcome everyone to introduce themselves in the chat so that we know who's here. We're going to start with a presentation and some commentary from our experts here and then we'll invite you to share your questions and thoughts. And by which you can do that using the hand raised function that's at the bottom of your zoom screen. And if you want to share thoughts throughout the consortium you can use the chat box to do so. So maybe let me just make sure that the chat box is open. Great. And I'm going to get started with some introductions here so please go ahead and feed in who you are and what you do, or what brings you here. On the next slide let me share with you where we're going today. So, as you saw from the title slide we're engaging what might feel like a fairly basic question. What's the value of a nonprofit hospital. But I think that you'll come to appreciate that this issue is far from settled, especially in the relative complexity of today's healthcare landscape. And we're very fortunate to have Dr. Lauren Taylor here today to lead us in this conversation. Lauren is a great friend to the organizational ethics consortium but also because we're catching her at a really great moment in her research on this topic where the empirical results have come in that the implications are still somewhat in development. And so that makes this conversation and your thoughts here today really doubly impactful. So, Lauren by way of introduction is an assistant professor at NYU Grossman School of Medicine in the Department of Population Health, and her current work focuses on the ethical challenges associated with managing healthcare organizations and markets. And her research has been published in numerous academic journals like Health Affairs, Hastings Center Report, Kennedy Institute of Ethics Journal, and then also news outlets like the New York Times and the New Yorker. I'm excited to think of Lauren as something of a local in part because she received her doctoral training here from the Harvard Health Policy Program and then also for broader training in ethics as an oncology chaplain at Mass General Hospital and in the office of ethics at Boston Children's Hospital. So, welcome back Lauren. We're very happy to have you. We are also fortunate to have two excellent commentators today to develop this topic further. So first, Dr. Nancy Kane is a scholar of management and public health, and she's a now retired professor of management at the Harvard TH Chan School of Public Health, where she also directed the master's in healthcare management program. So she served in numerous policy advisory roles, including as a member of MedCAP which is the agency that advises the US Congress on issues affecting Medicare. And also locally in Massachusetts as a member of the Massachusetts Special Commission on healthcare cost containment. And Nancy's extensive research on the performance of health systems has developed foundational concepts and evidence for evaluating the charitable activities outcomes and status of nonprofit hospitals. So we are extremely grateful to have Nancy with us today in this conversation. And then finally, Professor Jonathan Marks, who is a bioethics and institutional trust and integrity expert. He directs the bioethics program at the Pennsylvania State University, where he's also a professor of bioethics, humanities, law and philosophy. And Jonathan is also something of a Harvard local in the sense that he was a faculty fellow at Harvard's Edmund and Lily software center for ethics, and was affiliated with their lab on institutional corruption up through 2015. And his recent book, which is entitled the perils of partnership industry influence institutional integrity and public health critiques public private partnerships. And Jonathan also has a forthcoming essay on the ethics of crisis management coming out in Hastings Center report that will further build on the books exploration of trust, trustworthiness and integrity. And Jonathan has also done a lot that beyond that scholarly work, including serving as an expert on ethics and human rights in meetings of the World Health Organization the National Academies, the Royal Society and Hastings Center. So we have a fantastic group of presenters and commentators to bring us through today. And I think with that, I will turn it on over to Lauren to get us started. Thanks, Kelsey. It's so good to be back here and really, I'm just so chuffed as the Brits would say to have Nancy and Jonathan here as kind of co conspirators and conversation partners. So what I'm going to present today is work that I have been doing with the team, who I'll tell you about in just a moment we're at the phase of this project where we've collected data, and then a number of the preliminary analysis. But as Kelsey said the paper is not completely written. It's drafted about two thirds of the way through. And so this is a really nice moment for me to be engaging with you all, what a great turnout looks like we have nearly 60 folks here. So I'll potentially push on the empirics and say to me like look Lauren I just don't buy the argument or I would need to see the following analysis in order to buy it, and help me think broadly about what the implications are here. I have some ideas, I know that Nancy and Jonathan has better ideas, but I'm hoping we can crowdsource really the discussion part of this paper, a bit together. So with that, let me share my screen. And get going. Okay, so I'm going to plan to take probably about 25 minutes here. I will say that I am of two minds on this presentation entirely. One part of me thinks rush through your presentation Lauren because really Jonathan and Nancy are contributing a big chunk of the value here. And then the other part of me prompted by Kelsey really wants to make sure that I'm walking through, you know, the methods of how we collected this data, and as much granular richness as I can. And so I'm going to try and thread that needle as best I can but just to let you know what I wrestled with and putting this deck together. So the presentation is what's the value of a nonprofit hospital. And I try to shed some light on this through results from a national survey, the team, just so you can acknowledge them if you know them. I'm Amanda Zink from NYU Langone, who works with me, Andrew Fair as well as at NYU Langone, he's our kind of coding and data management guru, and then to associate professors from Ohio University Berkeley funds and Cory Cronin. So I am presenting on behalf of the team today though of course, all the errors and foibles are entirely new. The biases of what I hope to convince you of or the kind of story as I see it before I jump in and walk you through it in some detail. One of the most prominent defenses of nonprofit hospitals is what's known as contract failure theory, which was made famous by a legal scholar Henry Hansman way back in 1981. What Hansman was saying was really, he started with a question, why do we see nonprofit firms emerge, particularly in marketplaces where they compete directly with for profit firms. And the query was just what predisposes markets to give rise to nonprofit entities. What he said is, you know, the reason that we see nonprofit firms, particularly in direct competition with for profit firms is essentially because nonprofit firms signal a certain kind of trustworthiness. And that's particularly important when you have a market where your consumers and your sellers have stark information asymmetries. In healthcare for a moment you can think about patients in the consumer position, hospitals in the seller position. And as we all know, patients have trouble adjudicating is this a good or bad hospital is this a good or bad doctor. And so there are these information asymmetries in healthcare that lend themselves to Hansman's analysis, which would make you think, huh. Maybe the reason we have hospitals in healthcare at nonprofit hospital and healthcare is because when patients are out there trying to make sense of a market landscape and trying to figure out. Okay, like which of these institutions do I trust to go under the knife with or to become financially vulnerable to. They say, I'd rather trust a nonprofit hospital than a for profit hospital. The reason that Hansman lays out here is, well, why would they rather trust a nonprofit than a for profit. The key difference for him is in the legal status of a nonprofit hospital. And he says, look, we have to think about the non distribution constraint, the non distribution constraint is that rule that says if you're a nonprofit firm, when you have money left over at the end of the year, meaning you took in more than you can, you cannot distribute that money or those profits to external owners stockholders essentially. And for Hansman, this non distribution constraint is what increases the trustworthiness of nonprofit firms considerably. And he believes or at least put forward in these early papers that people who are trying to figure out where to seek healthcare. The non distribution constraint as a signal of trustworthiness and that is why people both prefer nonprofit hospitals and that's why nonprofit hospitals continue to exist in an otherwise crowded marketplace of different ownership types. I can go through that in more depth and we can always return to it but that's essentially the thumbnail. That's Hansman's theory. That theory rests on three assumptions. And those assumptions are what we tried to put to the test in this empirical survey, I'll unpack them in just a moment. The survey results that I'll show you have about 2700 respondents, we collected all the data back in November of 2022. I think, even being generous towards the kind of underlying theory, we have evidence that at least two of the three assumptions don't hold up empirically. If that's true, then I think that sends us back to kind of a first principle questioning about okay, if the value of nonprofits is not that they signal an increased trustworthiness in a healthcare market riddled with information asymmetries, then what is the value of a nonprofit hospital. And that's where I think our conversation can go. So, just to root this a little bit in some of the kind of local news and popular debates about nonprofit hospitals, some of you may have seen the daily the New York Times podcast had a big piece. I think this was maybe December or January, how nonprofit hospitals put profits over patients. That was kind of a summative podcast that recapped this multi part series that they were doing called profits over patients, where they were kind of doing deep dives on nonprofits, not unquote misbehaving or behaving like for profit firms. I will just be very candid my own employer was among those spotlighted in this series, and why you laying down with spotlighted as having a quote unquote VIP care or service line in their emergency department, which the New York Times spotlighted as, you know, certainly being inconsistent with the idea of being a charitable institution, maybe more broadly inconsistent with some of the principles of medical ethics. But this just kind of seems to be in the water. And, you know, as Nancy could speak to it seems to be in the water in a cyclical way it's like every 1015 years there seems to be this moment of national reckoning, both on the public side and on the policy side where people say, What are we doing with these nonprofit hospitals are they really doing what we expect them to do what do we expect them to do. And it seems to be a moment of reconsideration right now. So I should say, you know, one way to think about the value of nonprofit hospitals is to say, look, the value of having nonprofit hospitals in a marketplace that has both nonprofit and for profit hospitals. Is that nonprofit hospitals produce something different. So we actually get different stuff out of them than we otherwise would if we just were to say, What the hell, let's have all for profit hospitals. And what we get out of nonprofit hospitals you could think about a few ways you could say, just hypothesizing well you know maybe we get better quality healthcare. You could say, Well, maybe we get lower cost healthcare. Or a third option would be, maybe we get more kind of community benefit spending or more community investment. And, well, this is like a huge empirical terrain. There's lots of papers and scholars and constantly turning on this stuff. And that in none of those three domains quality cost or community benefit is their consistent narrative over the last 1020 30 years that we are getting different production out of nonprofits than for profits. You can challenge that claim. It's a bold one because like I said I'm summarizing there hundreds of articles, but that's my read of the literature. What he's doing, although he may not have known it is contributing a different justification for why we might have nonprofit hospitals. So I could say to you, look, I don't care that nonprofit hospitals do not produce something different. They can produce exactly the same thing that a for profit hospital produces. There may still be value to them existing in marketplace, and that value may be around what they signal. And so this is kind of this contract failure theory, as I have understood it. The contract failure theory, this is just voicing over what I gave you a few minutes ago but it's complex so let me do it one more time. I'm kind of there the kind of famous economist insight that information asymmetries define healthcare markets. Nonprofits are legally defined what makes them nonprofit in some sense is that they face this non distribution constraint, they cannot distribute net revenues or someone call them profits to external shareholders or stockholders. Because they can't do that patients perceive them as more trustworthy, because patients say to themselves, well, what's in it for a nonprofit to exploit me. If they can, if they have no principle waiting in the wings to send the money to what's in it for them. And so the sense is, they don't really have the same incentive or as much incentive as a for profit firm would have to exploit me. And so I perceive them to be more trustworthy. So in signaling this kind of trustworthiness, nonprofit status lubricates healthcare markets and provides important social value, it may induce people to seek care who would not have otherwise sought care. And that is a value that could not be produced by a for profit competitor. But if you think about what's the value of a nonprofit hospital I've now put forward two kind of branches to the tree. One is about what they produce and the other is about what they signal. I don't feel convinced by the production thesis. At least I don't think the empirical evidence has shown any kind of home runs there. So this what I'm presenting you today is an empirical test of that signaling theory thesis about what the value of a nonprofit hospital is. I just slide in just to kind of hammer home the fact that this handsman theory is not some backwater, you know, legal theory that was published in the 80s and never returned to what you see is on the y axis number of citations and on the x axis, just some key papers that you all may be familiar with. So just for giggles. The first one deficits and psychological and classroom performance is the key paper showing that lead is harmful to human health and sitting with about 2100 references. Bless those authors over here right next to the orange bar you can see Don Burwick's classic the triple aim with about 5700 references and handsman's key paper or one of the key papers putting forward this theory. The earlier theory of nonprofits has about 5300 references. So widely widely cited, both within healthcare and beyond. So my read of this theory is in order to buy it in order to think yeah that's really the way the world works. You would have to buy three assumptions that are buried within it. One is that people consider ownership status relevant to decisions about where to seek healthcare. The third is that people have a preference for nonprofit hospitals over for profit hospitals. And the third is that people can correctly identify nonprofit hospitals in the wild. If any one of these falls down, meaning we can't bring evidence to bear to substantiate it. I think we have to question whether handsman's theory as he first described it is really a descriptive theory that tells us how the world works. This is why we have nonprofit hospitals, or with this organizational ethics group in mind. Maybe he was putting forward more of a normative theory, like, this is how he wishes the world worked, where this is how patients or consumers should make decisions, but it's not really a description of how they actually do. So getting to the empirics we essentially took those three assumptions that I just walked you through and transformed them quite simply into research questions. So our research was guided by an interest of do the American people consider ownership status relevant for hospital care. Do people have a preference for nonprofit hospitals, and then can people correctly identify nonprofit hospitals in the quote unquote marketplace. I'll return to this graphic a few times but just to think about how we would keep score on this if you will. We've got relevance preference and the knowledge. My feeling is that for contract failure theory to really hold up as an explanation for what the value of nonprofit hospitals is, you would need check check check all three. And after I present you the results will check in on how the empirical data stacks up. So what did we do, we fielded an online survey in November 2022. This was distributed through a paid panel survey company so this is a company that pays people and kind of keeps them on retainer to take surveys and get paid for them. The sample that we wound up with like I said was about 2700 people and that sample was balanced roughly with the US population on age gender race political affiliation in region. I'll show you what that looked like in the paper will of course include details but think of it as roughly balanced participants were paid for their time and this was IRB approved through NYU. The survey took people less time than we anticipated to, to complete people who take surveys professionally, more or less tend to be very fast at them so I think the average time was closer to the seven minutes than 10 minutes. But you can see here kind of the gamut of questions that we ran them through informed consent. There was an education page saying a little bit about kind of key terms. There were quiz questions that I'll show you in just a moment. We asked them about what do you think would happen if a local hospital went from a public hospital to a nonprofit hospital or a nonprofit hospital to a for profit hospital. There were some questions about their trust in doctors and healthcare generally, and then we had a whole battery at the end of demographic questions. Let me just show you because the kind of quiz questions if you were will are in some ways, the most important and the most interesting. So each respondent who took this quiz. The following question. For each of the following organizations, what do you think the organization's profit status is, and we selected these six, what we called national brand hospitals. And we put them forward because we thought there was a good chance that people had heard of them, although we gave people an option as you see on the far right to indicate that they had never heard of them. And then we asked people essentially a quiz question, what do you think it is. And so you can see it's Mayo Clinic Cleveland Clinic, MSK in New York cancer treatment centers in America, St. Jude's and Belleville. Then we also asked people about hospitals in their hometown, essentially, and this was what required a little bit of innovation and creativity. We knew that if we only asked about national brands in healthcare, the critique would come that, well learn why would you expect someone to know what this quote unquote national brand is it kind of bears no relevance on them what ownership status the Mayo Clinic is if they live in Arkansas. So in order to meet that critique head on, we said okay we've got to design a survey that enables people to give us their best guess about the ownership status of hospitals near to them. So what we did was we asked people, give us your first three digits of the zip code. When they gave us the three digits of the zip code that essentially queried a back end lookup table where we had programmed all of the hospitals in the United States by their zip code. And we rigged the survey up through some coding magic to then present respondents with hospitals in their three digit zip code. So if I put in 110 as my home zip code, I would only be presented with hospitals to guess whether their, their ownership status was nonprofit for profit or public that were in that three digits of code. I'm happy to say more about why we chose a three digits of code, but just to give you a sense there are about 983 digits of codes in the United States. 88% of the three digit zips in the United States have at least one hospital in them, and the average number of five of three digits of code hospitals, sorry hospitals per three digits of code is about five and a half. So it just worked out to be a nice geographic unit where we could ask people up to three hospitals to give us their best guess at ownership status. They were likely to have hospitals near to them, etc. We tried on other things for size five digit zip codes area codes, etc. And we just found kind of a Goldilocks principle that this was the right unit for us. So just telling you a little more detail in terms of the results about who took the survey. You can see here, kind of a comparison of our sample against the US population. Orange bars are the US population blue bars are our sample. Interestingly in political affiliation. There are many more people who claim to be independent in the US population than there were in our sample so we were overrepresented on both Dems and Republicans compared to independence. As is the case with a lot of online surveys we were slightly underrepresented in terms of the 60 plus crowd and overrepresented among the very young. That's reflective of who spends a lot of time online and who spent a lot of time taking surveys online. And actually, we did pretty well racially and ethnically in terms of the demographics and gender we were very close to balanced, according to the US population at the moment. So let's get to the three questions. Do people consider ownership status relevant. Do they prefer nonprofit hospitals, and can they correctly identify them on the first. Do people consider it relevant. Kind of a simple question to answer in some respect just a straight descriptive, we asked people. Have you ever considered ownership status relevant in deciding where to seek health care, and only 29% of people indicated that it ever had been relevant to their decisions about where to seek health care. Less than a third. This relevance issue varied in some interesting ways based on demographics. I'll tell you just some of them. In terms of insurance status, people who are on Medicaid, or are rather under 65 and on public insurance is how it was strictly coded in our data, highly highly relevant to them, almost 75% of people who indicated they were on Medicaid said yes, ownership status is relevant to me. People who are on Medicare, so over 65 and on public insurance said, I think it was less than 15% of them indicated that ownership status was relevant to them. Not necessarily something I would have known to predict ex ante, but in retrospect kind of makes sense. Medicare tends to be generous in its coverage for hospitals. I know Nancy has additional thoughts on this but we could hypothesize the drivers for people who are enrolled in Medicaid's reticence to maybe get stuck at a hospital that is either not nonprofit or not public, and then be stuck either with kind of discriminatory or large bills on the flip side. Health care worker status actually turned out to be very associated with whether or not people thought that ownership status was relevant. So if you are in the health care field, you say yes that is what my day job is. You're almost three times as likely to say yeah, ownership status is relevant to me about where I seek care. One of the strongest effects we saw in the whole survey data analysis. We saw health literacy, we saw essentially a dose response relationship with people who said I often are always have trouble understanding health information, saying that ownership status was much more relevant to them. That was a little bit surprising. I'll say there were lots of surprising things in this project but this was one of them. The findings are clear and consistent that people who have trouble understanding health care information, nonetheless think that this potentially backwater issue of ownership status and is the hospital nonprofit or for profit or public is very, very relevant to them. Whereas people who say no I never have trouble understanding health information, it is considerably less relevant to them. The last one just to mention is education. And it was worth mentioning only because you see an interesting kind of horseshoe effect. So the people who say that ownership status is most relevant to them. It's essentially a tie between people with less than a high school degree and people with a graduate degree. So you've got high watermarks on the two ends of the education spectrum, and then kind of a dip in the middle where people with a bachelor's degree or about 5% less likely to find ownership status relevant than either of those two end groups. So I will say with 29% of the total sample indicating that relevant stat ownership status is relevant to them. I'm going to put an X here and say that the theory does not reflect, at least broadly, the kind of perceptions and behaviors of the public. Although if anyone wants to come back and say, I disagree, I'm happy to have that conversation. Let's go to preference. So the research question was do people have a preference for nonprofit hospitals. How did this information via display logic. So what that means is, we first asked people has ownership status ever been relevant to you and decisions about where to seek care, then only if they told us yes it has been relevant to me. Did we ask them for their preference. The reason we did that is because classically in survey design you don't want to ask people questions that they don't have a preformed opinion on because it essentially just introduces noise into your data. The logic by which we did this, I will say if I were to do it again, I might do it differently, because I never expected such a small portion to say that it was relevant. So we had 2700 people answer the relevance question, but then our numbers dropped considerably down to an end or a sample size of 864 for the preference question, because so few answered the prior yes. As I said, among people who answered the question at which kind of facility do you prefer, prefer to receive care. We gave them three options for completeness nonprofit or profit and public hospitals those are hospitals that are largely funded out of a tax base usually often municipal could also be state or federal the VA system is often a federal system. And this is the results. So 29% is again our magic number of the people who answered the question 29% indicated they preferred nonprofit hospitals. This trailed considerably the stated preference for public hospitals which was the kind of winner of the group at 55% and then 15% of the sample said they prefer for profit hospitals. We also assess this preference issue through a little bit of a backdoor manner. If the question I just showed you about, which is your favorite kind of hospital is an assessment of people's explicit preference. We tried to get at people's maybe implicit or unstated preference in the following way. I mentioned we had asked a series of trust questions. When we knew what hospitals were in people's three digits of codes that gave us a chance to ask them, how much do you trust this hospital. We had for each person how much they trusted the local hospitals that we had shown them, and we as survey designers knew what profit status or ownership status those hospitals were that gave us a chance to aggregate across the whole sample. What is the average level of trust in nonprofit public and for profit hospitals. You see at the bottom of the slide here how we asked this question to respondents. The question is kind of a standard one we didn't make it up. How often do you think you can trust the following to do what is right for you and your family, and it's a one to four scale. And the results are down here at the bottom, and they're very tightly clustered. So people said, essentially the mean was a 2.91 on a four point scale for a nonprofit hospital. Upper edge of, I trust them some of the time moving towards most of the time, but public hospitals were 2.85 and for profit hospitals were 2.81. There's not a formal statistical test to be run here to assess the difference between these means because they're all on the same sample. But to my eye, it's very small differences. Now it according to my intuition, I would have told you ex ante this was my guess of what people's trust in these hospitals were, but very very small I'm not sure I would put a ton of stock in this rank order, with only 0.1 on a four point scale difference. So if we go back to keeping score. You know, I think this is the, the domain if you will, where I want to be most generous and say like we don't have irrefutable evidence that people don't prefer nonprofit hospitals. Nor do I think we've got a lot of evidence that nonprofit hospitals are running away with it in terms of the preference game. So I'll put a question mark for now and keep going. Now it's kind of the most fun one, the knowledge based questions. The question we asked the research question again was can people correctly identify nonprofit hospitals. And we did this according to that question structure that I showed you before. So you can see the results down below. And what you see in the gray column is people who said, look, I've never heard of this hospital so I can't even venture a guess about what ownership status it is. Here you see the true ownership status meaning what it's actually registered with the IRS as, and then this column is the percent that got it right. So St. Jude Children's is clearly doing something right or strategic in communicating its nonprofit status, almost 75% of people correctly identified St. Jude's as a nonprofit. My thinking on this is frankly because they do a lot of television advertising, and that television advertising makes direct appeals to the public for money. And that's how people think about nonprofits as constantly fundraising and asking for money. And so there you go, St. Jude's is well understood. And you can kind of just look down this Bellevue is our public hospital in the set, you know, and they didn't do badly in the scheme of things. Thank you, David Oshinsky, I suspect for popularizing Bellevue and its municipal status. And then just to mention one other here, Cancer Treatment Centers of America is our for profit hospital in the set. And it is the one that people performed worse on and I will tell you in an opportunity to give some open text box responses. People were, they were, they felt almost betrayed at the idea that Cancer Treatment Centers of America was a for profit hospital. My sense on that is because they do do a lot of television advertising. Their advertising does not ask for donations. It asks for patients to come to Cancer Treatment Centers of America and receive care, but I think that the difference between asking for donations and asking for patients to come is not always appreciated by the public. And so many, many people thought Cancer Treatment Centers of America was nonprofit when in fact it is for profit. So then we get to the question about whether people do any better in their local marketplace. And this is where we were using that fancy bit of coding to show people hospitals local to them. The respondents who indicated that they had heard of any given local hospital, less than half correctly identified the ownership status. And then specifically, when we showed them a nonprofit hospital local to them. The sample performed worse than random chance given the three options. What this looks like just kind of broken out by profit status. So when we showed them a hospital that we knew to be nonprofit, and we asked them, what do you think the profit status is 24% of people correctly identified that hospitals and nonprofit 44% of people thought that hospital was a for profit and 32% of people thought it was a public hospital. You can see down here people actually do better when we show them hospitals that are actually for profit or are actually public. They're not hitting it out of the park, but they do a little bit better. What you should take from this slide is that people actually have the hardest time correctly identifying nonprofit hospitals, they do worse when they're shown a nonprofit hospital. Then they do when they're shown a for profit or a public hospital that is local to them. Just to summarize this, you can get a sense of what people's imagination is about the kind of national landscape of hospitals from this data. What you can see here is blue bars are what the actual proportions of the whole US healthcare hospital marketplace are. So you have, I think somewhere between 5000 and 6000 hospitals. About 65% of them are truly nonprofit 16% of them are truly for profit and 19% of them are truly public, and the orange bars indicate if we are to extrapolate from the samples guesses, what they think the landscape is. The landscape is much more for profit than it is, and actually much more public than it is. And they vastly underestimate how many nonprofit hospitals, there are. So this leads me to put an X. I think my most emphatic X of the three next to knowledge and awareness. And we asked, we gave people an opportunity to weigh in and sort of an open text or free text way and we did this after we said look do you want to know the right answers to the questions that we Christian on more than half of people said yeah I want to know the right answers. And they were given an opportunity to react so this is when we get some of that color commentary on cancer treatment centers of America, and elsewhere. And I wanted to show you this first set about people's comments specifically related to trust because trust is so at the heart of handsman's theory about why nonprofits are valuable. And I will say people offer comments that cut in diametrically opposing ways. So this first comment is someone said, you know I'm pleasantly surprised that most hospitals are nonprofits, but even more surprised that CTC of a is for profit. Trust them less overall. So this is a comment that very much jives with contract failure theory. This is someone saying CTC of a is for profit. You can kind of fill in the gaps here about why it might be but dot dot dot ellipse that makes me trust them less overall. So this is someone who likely has a preference for nonprofit or a public hospital over this for profit one. And there are other kinds of comments in our set as well. And this other one is representative that and someone said, I feel I would trust a for profit hospital over a public or a nonprofit hospital or clinic, and they don't give a rationale for that, but we could kind of put forward some hypotheses. I'm going to skip these two just briefly and close with implications. I have shown you data now that suggests that Hansman's 33 year old theory does not align with empirical data that we collected in November of 2022. That could be either because look, a lot has changed in health policy and healthcare marketplaces, and he may have actually put forward an accurate descriptive theory of how patients were making decisions in 1980 81. As I said before, it may be that that was never an accurate capturing of how people actually behaved, but it was more of a normative theory than a descriptive one. The kind of key takeaway here is that Americans understand the differences between hospital ownership status is quite poorly. And so the value of nonprofit hospitals then seems not to be in its signaling value, because whatever they're trying to signal people are not picking it up. And so that either leads us back to a consideration of, okay, can we do different kinds of analyses, or find something more meaningful in this question about what nonprofits produce. Or we really go back to first principles and we say, okay, it's not in what they produce and it's not in what they signal. What is the public value of a nonprofit hospital. I'm a few minutes over I'm going to pause and really look forward to Nancy and Jonathan's comments. Thanks. So much Lauren. All right, let's bring Nancy and Jonathan and I think Nancy you're getting us started. There we go. Can you hear me. Yep. Okay. So yeah, it's very entertaining and I, you know, I've been involved with looking at the not the tax exemption and charitable status of hospital since the 70s. I predate enhancement. I think one of my earliest experiences as a physical therapy student was patients who were self pay who got sent giant bills, and we're horrified so you know I kind of got cynical about nonprofits data early in my career and I just kept that cynicism throughout. So I think what Dr. Taylor is finding shows there's at least some ambivalence in the general population about what nonprofit ownership means to them and you know I think the 29% who said it mattered and then versus and then the 29% of them who said nonprofit with what they preferred leads us about what 9% of people saying that they thought it was significant and they wanted a nonprofit which is not a real testimony to the value that the signaling values of the ownership status. But anyone who has studied nonprofit or health system behavior is probably not too surprised. I see some of the comments in chat that go right along with what we're I'm going to say that I think health system behavior. Is is much more important than ownership status. And private enurement is really only one of the many economic incentives, influencing the way systems behave both for profit and nonprofit. To me the most pernicious influence from the perspective of patient trust is that we believe in competitive markets as a means to distribute resources. And that whatever your private nonprofit or for private you've got to compete for both operating and capital resources in private markets. So you're going to be responding to the incentives of private markets not to some theoretical legal status that doesn't fund doesn't pay the bills. So to be competitive and ultimately survive in a competitive market. Most systems have to earn the revenue from patients to cover their operating expenses. This is not philanthropy many, I think St. Jude covers a lot of their expenses with philanthropy, they're unusual Shriners you did that for burn care. But most systems don't get that kind of philanthropy and so they have to earn that money to cover their operating expenses, and people don't work for free anymore, maybe back in the 50s when there wasn't Medicare and Medicaid a lot of, you know, the religious hospitals have relatively cheap labor but people don't work for free and you have to earn the revenue to pay them. So, the private market requires that you, you know, collect earn your revenues actively. Now earning revenue, unfortunately, can create a, what shall we say some conflict with patients because it can involve collecting patient money directly from patients, pursuing patient debts through collection of financial credit of the patient at risk and billing insurance companies that requires so much staff that I think it makes elevates our healthcare expenditures way beyond that of countries that don't have a private insurance market. So, you know, earning revenues a very expensive proposition that we as a country have bought into and believe is very, very important. And maybe even more importantly, it has motivated strategic behavior, so that the private nonprofit hospital can gain market power relative to mostly their for profit insurers. You know, hospitals can sell have been consolidating for the last 20 years, really, mostly into larger and larger and more influential multi hospital systems, and or they're expanding their services and facilities to serve better insured patients and more areas. And they're actually closing services and facilities that serve low income and low paying patients. I mean the Wall Street Journal recently published an article that showed that many religious nonprofit chains had tendencies to acquire hospitals in more affluent areas and to divest the hospitals that they owned in low income areas. The closure of a nonprofit hospital, whether it's got a saint before its name or not, gives the general population a pretty big feeling and it really harms their, their health care access. And that's been going on really for the last 1015 years in particular as health systems get larger and own more hospitals and and view those hospitals as a portfolio that they can sort of trade in just like at your, your investments for your retirement fund. I will say, the other thing that I think has harmed the trust of populations in the ownership status is that these very large health systems as they've consolidated have taken the local control away. It's now remote governance structures. They're not accountable to the communities they serve. In terms of senior management, the board members are no longer visible and respected members of the community and a faceless bureaucracy just does not engender patient trust. So that's been another fact that a nonprofit and a for profit industry that has not engendered trust, regardless of ownership status. And people don't understand that a nonprofit, a private nonprofit has to earn profit, and I taught accounting for years and I always love it when people say, well, aren't they nonprofit doesn't that mean they don't earn profit. They do earn profits they have to earn profits. My first job in in Massachusetts was setting rates such that hospitals could get a meet their reasonable financial requirements, which is in that how much basically say how much profit should they make. The key variables are how much do they have to pay to repay their debt. How much do they have to invest in property plant and equipment. These days how do you invest in information systems so that you can, you know, stay competitive with the rest of the world and other very expensive infrastructure projects like taking risk for accountable care organizations. The answer me used to be a significant source of capital for a lot of health systems, but it doesn't come close to meeting these kinds of capital requirements and today's health system. Profit is the major source of capital for nonprofits and for profit to like in the private sector, even when you borrow to meet your, you know, your capital needs, you have to repay that debt out of operating cash. And that long term debt private nonprofits and for profits are in private capital markets. So they're subject to the credit requirements of private investors who can consider how you know whether they'd rather give you money and use a nonprofit or invest in a bank. The large. So what they do with nonprofits for a lot of creditors require is very large cash balances to give them the security they're going to get repaid. So when there's been a lot of newspaper articles about the cash balances of health systems. Well, that's there to cover their long term debt obligations and that gives them favorable treatment and in tax exempt markets. So the, if you always you've got people competing in private markets, they're going to act like private, you know, they're going to act like for profits whether they're not proper or not. The one exception and it's consistent with Dr. Taylor's findings is that government owned systems are exempt from a lot of that pressure. And because of state and local legislation past decades ago that the commits the local county health district city, sometimes the state to be provider of last resort, and requires them to but to subsidize both operations and the capital requirements of these systems that they own. And this is done usually through local tax sources like property and sales taxes. So most of these, these are public hospitals, and that's what their source of capital is not in private markets, generally, unless the county chooses to issue the debt but they still often repay it through local property tax and sales tax. So most of these public hospitals have no incentive to expand beyond their local service area so they stay local. And they often provide special services tailored to the needs of low income communities that they serve from, you know, level one trauma center to translation services for those who have trouble with literacy. And they often provide free primary care to help people stay healthy because they're going to have to pay for the ones who get sick out of a very limited resource pool. The only thing about public hospitals is their governance is locally controlled. Sometimes even their boards are elected, which is not always great but they are very responsive to local community need. So I'm not surprised that 55% of respondents and Dr Taylor survey, actually prefer of those who had who cared prefer public hospitals over private ownership types whether they are nonprofit or for profit. The quality of private nonprofits along the same lines is that private enurement is is not much of a constraint when you get taken to account the trends and executive compensation, which is determined by the boards. These organizations have to compete for executive talent across the same industry and ownership classes that they have to compete for for capital. The nonprofit executive compensation is often in the news for seeming to the average person to be excessive, like, you know, in the high end $6 to $12 million a year and there've been some very high profile cases of nonprofit execs and the healthcare with huge, huge compensation. The Brown Institute just did a great study of the differences in hourly ranges across nonprofit hospitals, but the high end is the CEO is making $3,289 an hour, sign me up, and has a salary that's 60 times greater than the average health worker. I'm not surprised that people who work in these organizations can see some of those differences and think maybe they aren't so maybe the incentives to be kind and community oriented aren't fully there. The CEO compensation often includes performance based on bonuses that are based on financial performance, for example, more revenue and better pair mix. As one recent article concluded compensating CEOs for more dollars flowing through an institution is not conducive to better stewardship of the community's health. I think we have seen that in their, in their, a lot of their policies towards collections and a lot of their policies toward which hospitals and markets to serve. And I think it's, it's pretty pernicious and far worse than paying some dividends at the end with whatever profits you have left. So, okay, I don't have great faith that nonprofits, private nonprofits are going to be that trustworthy relative to any for profit. In terms of policy solutions. It could make sense to strengthen the definition of behaviors that must be documented to earn taxes and status, but we don't really have the bureaucracy to implement anything you know we've got plenty of data. The IRS form 990 already requires hospitals to fill out an extensive schedule age asking for all kinds of quantification of the value to uninsured under insured Medicaid shortfalls community infrastructure. No minimum standard and there's nobody there to say that's not enough. So, and I think to in order to get anybody any public oversight organization to start pushing on this would be. Well it's really kind of outside the expertise of government oversight in my experience and states have tried to do it as well. And I believe they're not past one of the most rigorous charity benefit charity requirements on their hospitals back in the 90s. And, and they collect the data but they don't enforce it. So, you know it's just very hard to go after these hospitals, because they always have a good reason to say whether not doing something that's in the best interest of their community. So one, one thing that I'd like to revisit is that the hill Burton program was around in the 1947 to 1971 that converted to another type of program. But that was when post World War two America had a real shortage of hospital beds. And this was a public solution to dealing with the problem of seeking, as I said before, seeking capital creates a lot of not such great behavior on the part of our nonprofits. Her Burton provided $28 billion between 1947 and 71, and was responsible for the construction of nearly a third of the hospitals existing in 1975. And these hospitals provide free care to indigent patients I don't think it did a very good job of monitoring it or enforcing it, but, but it, it's one way to say okay, we want more community oriented behavior. If you're not trying to please investors and creditors maybe we can, we can enforce better behavior towards taking care of people providing the services serving the markets that are right now, losing access to services and care. And I think there's a lot of, you're going to have to go out, the, you know, how do you create institutions that truly have charitable behavior is going to require a lot of thought into what really motivates the health system, and trying to address what's going on at that motivation level and behavior to me you know Trump's ownership status as the determination of community trust. With that, I think I will let Lauren make it if she wants to ask a question or comment. I look forward to her to her comments. I have reams of notes scribble but I'm conscious of time so part of me wants to go straight to Jonathan. Why don't we do that. Okay, I didn't see this was so rich also that I'll just say one of the big things that I'm hearing from you is that nonprofits seem to face the same pressures as for profit muscles. They act pretty similar to them looking at things like bill collection CEO compensation closing low revenue facilities, faceless bureaucracy and so it's probably no surprise the public can't tell the difference between nonprofit and for profit and in the public don't really see it as relevant. So that's a really helpful context for organizational behavior and how that influences things. Thank Jonathan you've got a little bit of a different angle. So let's bring you in. Why don't you share your thoughts. Thank you so much. It's a real pleasure to be here and to be part of Dr Taylor's work and to follow Dr came in her response so just a couple of things. I think immediate anecdotes, given that I can say that family members have received bills from so called nonprofits for $15,000 for an MRI and more than $800 for a 15 minute encounter with a specialist. You can imagine why some people will be surprised to find out that a nonprofit that an institution was actually nonprofit. This is very important. Well, not actually because of handsmen. Dr Taylor and I had an aside by email I think you know he may have refined his views over the years but I do think there are other reasons why this is really really important. And I should just say, before talking about those reasons that my thinking has also been influenced by the book that many of you heard came out this week. These are the plunderers how private equity runs and wrecks America by by Gretchen Morgensen and Josh Rosner and they tell the story. I think quite persuasively of how by 2020 to private equity firms. Blackstone and KK are the format through subsidiary team health a ladder through envision and M care had acquired one third of the emergency rooms in the United States and if you include other private equity firms, the figure went up to 40%. If you dig a little deeper through other sources you learn that often what happens during these acquisitions is that the private equity firms convert the hospitals from not nonprofit to for profit. They often sell the capital assets the land on which these institutions sit, and then the hospital systems have to rent at ex exorbitant costs. The property in which they had been operating from. There's lots to be deeply concerned about and I would add just to be clear that the, the full grassroots organization doctor patient unity, which was lobbying against the no surprises act to the federal legislation to reduce surprise billing was essentially by blackstone and KK are these two private equity firms so, so there's a lot going on in the healthcare system right now. In addition to the structural incentives, the doctor came very helpfully articulated. I would like however to focus my comments on three concepts I think are incredibly important here trust trustworthiness and integrity. And I'm going to say a little bit about what I mean by trust and trustworthiness and why they're important first. So, trust, I consider to be an attitude toward an individual or an institution based on your perceptions of that individual institution. Trustworthiness, on the other hand is an attribute or a property of that individual or institution. And this is not simply a sub, you know, a semantic difference it's a really important one. It is relatively easy to determine whether or not people trust institutions. That's part of the research that Dr Taylor has presented today you ask people and surveys, or through focus groups are delivered to deliver to pulling people who trust this for profit hospital or not for profit hospital, but figuring out whether an institution is in fact trustworthy is a much more complicated exercise. It requires you among other things to think about whether what they say they do is actually what they do and sometimes there's internal messaging in an institution that is totally inconsistent with this external messaging, but you don't necessarily have to be an outsider. I think it's incredibly important that we keep in mind this distinction between trust and trustworthiness, because it is problematic when people trust an untrustworthy institution, and is certainly problematic to bolster trust in untrustworthy institutions. Let me say just two other one other thing about my taxonomy here and then I'll tie it to Dr Taylor's research within these categories of trust and trustworthiness, it is also important to distinguish among competence, fidelity and reliability. In the case of both trust and trustworthiness sometimes what we mean is we, we trust someone or some institution to be competent. That means we believe they have the knowledge and skills and the capacity and resources to perform the functional task we are entrusting them to perform. If we believe them to have fidelity trust or they do in fact possess a trustworthiness related to fidelity what that means is they put others interests ahead of their own. And here what will be important with the interest of patients over the interests of pharmaceutical companies or the ownership of the hospital. This is rebut the reliability which is the third kind of trust that means you trust someone to do what they say they're going to do a concept that overlaps there we neatly within with some of my core considerations by integrity, about which I'll say more. Why is this distinction really important well I'm Professor Taylor share with me, some of the more detailed nuanced data from her study. There might be. When you look at the study and the data and it shows that some people believe you have slightly superior health care quality, perhaps in, in not for profits what they're saying is, that's competence trust. I believe they have the skills, resources, the capacities, the equipment, the expertise, etc to do what we trust them to do. Although, again, I think we might need to deal, dig a little deeper here because what it might mean is, you know, people trusted their doctors and nurses when they spend more time with them when they express more compassion and that may or may not be related to whether in actual fact, they're getting better care. There are options that nonprofits have fair billing practices, which was also something in the more detailed evidence, which the anecdote I shared with you at the beginning challenges. This really an example of what you might call fidelity trust believing that they're putting patients interest ahead of their own, and billing more fairly although of course, we needed the no surprises act because there are many examples of unfair billing. The third kind of trust also ties in with some of the data. Dr Taylor studies suggest that some people thought nonprofits do more for their community. And very often this is what nonprofits actually say we do more for our community so that in so far as it's a perception of them doing what they say they do that it really relates to reliability. Now, I want to step back and say the really important thing for me is whether these perceptions are in fact justified. And that's where I think we have to come to what I call institutional diagnostics. And for institutional diagnostics, I think it's important to think about four dimensions of an institution. One is the function of an institution what is it we need those institutions to do and we need nonprofits to provide accessible affordable health care to patients in need. Then the question is what is the purpose of those institutions. Now the purpose of the institution is established by its finding documents, but which usually establish its obligations but also by obligations that are recognized as a result of various statuses. And an example of this is section 501 C3 nonprofit status that nonprofit hospitals possess, and they get that status because it's tied to their charitable purpose. So that then reads leads us to the question, do they in fact provide that charitable purpose. And I'll say that the third component before we get to what they actually in fact do is the mission of the institution. What does it say it does and many of these not not for profit hospitals do say that they're providing charity care and they're serving their community. That leads us to the question their practices the fourth dimension what are they in fact doing as opposed to what people think they are in fact doing and on the slide earlier on in Dr Taylor slide deck was an article by by and others from health 2021. And what that essentially shows is that an actual fact, although you can quibble about some of the details nonprofit hospitals are not actually providing more charity care than other kinds of hospital and that is a real problem. So, what are the remedies then given that there's that there's a lack of integrity here that these institutions aren't in fact doing what they should be doing. And, you know, sort of can emphasize, one could think about beefing up the requirements for 501c3 regulatory status, but does the IRS really have the resources to enforce that. And then the second question is well what about then some other kind of regular regulatory requirement to ensure that these institutions are actually doing what they need them to do in an ideal world this is exactly what we would have, but I am deeply worried about the aspects of this, simply because of these incredibly powerful private equity firms like Blackstone and KKR that own so many of our emergency rooms and other health care institutions. So I do actually think the real question here is less related to perception, but to the actuality of what these nonprofit institutions are doing, and the profound need for regulation to bring them in line with what we need them to do, what we say them to do, and what in our most charitable moments moments we actually believe them to be doing. So I'll stop there. Thank you. A bunch of time for discussion so maybe let's just start with reflections from Lauren or if you guys want to pick up on any of the pieces just shared and then we'll bring in some audience questions. That was just so fabulous I feel like Jonathan, you know, I have a degree from a Divinity School and a business school and I feel like Jonathan spoke to the Divinity School of me and I was feeling. On paper 501c3 registered as a charity, show me the charity. You know, and Nancy and I share degrees from Harvard Business School, and she gave me the real politic of, look, this is the explanation for why they behave the way they do. You know, they compete in markets they got to raise debt, they've got to compete for labor. So I just wondered, Nancy, maybe I could throw it back to you, like, do you think it's unrealistic to think that nonprofits could really live up to that letter of the 503 law given our current health policy and health market structure. Well, some do. And I figured out how to do it. I mean, I'm on the board of a system that has is what's called an anchor Institute for their community. And they stay centrally, and they stay locally focused, they've expanded beyond the city to the, the, you know, the surrounding counties but they're, they're an anchor mission they believe that it is their responsibility for the community's health. And that's a function really of the board and the senior management team. They could change in a minute. So, I mean, if you can get a management team that aspires to sort of make the community healthy, and you can find a way to finance it. I mean, we never make money, but we get a lot of state subsidy. You know, we are private nonprofit but we have a lot of public subsidy. I mean, I guess that I think it's possible. I think it's really hard to legislate or regulate behavior. This is why I go to like the Albertan equivalent I think how federal money gets distributed and how might federal and state public money gets distributed might play a big role in getting the kind of behavior you want. I'm unfortunately coming down to money. I like the thought that people might just altruistically run organizations to serve the community. But if there's not, if there's no money there they don't do it or they go bankrupt I mean you know a lot of a lot of a lot of the public hospitals that serve local communities. The taxpayers get tired of dealing with them and spot them off to private equity to then close them. There has to be a way to provide the money to keep these places, local and community focused. And that's what I think we need to come up with. I don't think we can, I didn't go to Divinity School so you can, you know, I'm probably missing some spiritual component here. But I don't think people in private markets are going to act differently than what we're seeing. My only pushback Nancy, and I'm interested in your thoughts is where you say, you know, I don't think we're very good or we know how to really regulate behavior. And I think in healthcare we regulate behavior down to the minutiae of who gets access to this particular prescription thing in the pharmacy and who gets to sign off on these charts like we regulate behavior deep into clinical practice. What makes you so hesitant to say that we could regulate behavior around kind of the charitable activity at the organizational level. Well okay so I started working in healthcare cost containment in 1976. For state regulation and I work at the feds around this and I work with other states around cost containment and trying to keep healthcare affordable for people. I've always been what is that now 3040 years, and I don't feel like we've cracked the nut on, you know, keeping healthcare affordable. I've also helped Attorney General suit nonprofits that don't take good care of their, their indigent and their low income people. I mean, the Texas law came about because of a lawsuit from the Attorney General saying, you know, a particular hospital was not terribly challenged their taxes of status so there are local tax exam status challenges all around the country often for different reasons not just because they're not being charitable because they're removing taxable property from, you know, local roles. So there's, I mean I've been involved with different efforts to try to force more charitable behavior, and the most successful ones frankly have been at the local level. Like I, my, my students help get, you know, make Provena loses taxes and status for a year, and got that incorporated into the tax exam, you know, market considerations. I think you have to go after where they get their money and create bells and whistles around that. And, you know, certainly revoking tax exam status is a great way to get people's attention because so much of their money is from tax exam debt that they have to repay if they lose that status. So, I mean, there are ways but I always go to you know how are they paid, and how do you get them to do things in a more charitable way. And we've just been terrible at articulating that and I think that we keep thinking of when we pass Medicare and Medicaid few now they're not going to be any more indigent people. You know, and then we got affordable, you know, the ACA, which by the way, had a whole slew of additional behaviors that nonprofits had to behave, you know, accommodate, you know, community health needs assessments. Average gross, your billing had to be, you know, for indigents was constrained that now they're doing all kinds of things at the federal level, but it's still a bit it's gotten worse, if anything, in terms of how uncharitable so many places have become a major reaction is your gut do away with nonprofit status just make it a level playing field government recoups 25 billion a year and what the subsidy otherwise kind of costs us and go from there, or to maintain the status and try and strengthen it, but keep this kind of bipartite tripartite division. I had my brother and then personally remember the 25 billion goes to local state and federal so that's not one big chunk of money. Yeah, so you got to work across three layers, you know, they've got sales tax exemption they've got property tax and then they have income tax exemption and of course I'm sure they can make a lot of that income tax go away with creative accounting, but I won't go there. Yeah, maybe revoke it and then say you can get it back if you do these five things, which is, instead of saying just because you claim your 501 C3 we're going to take it. I mean the only time it ever really gets revoked isn't when something really egregious happens and usually it's not because the IRS or a state or going to seize it is some local media person who does a story about something terrible just happened. There is no monitoring right now. So maybe you know as it's, you know, take it away and then say you got to earn it back doing these types of things, but but that requires a huge oversight that we just don't that capacity has not been visible and the 4050 years I've been working at this. Yeah, so I think one of the problems we have in terms of the regulatory framework in the US right now is, there's not enough real exposure for leadership, right. We saw this in relation to the opioid crisis, people can hide behind their corporations and behave egregiously as we saw in the opioid crisis, more direct personal liability. You know, you can be, you know, for a while I was a, you know, I was a practicing lawyer in the barrister and full time in the UK, and you could be disqualified from becoming a director as a result of your behavior while being a director. You could really tighten things up if you if under your watch your institution loses 501 3C status. What about you being disqualified from from at all or for a period of 10 years from running a nonprofit there are lots of things you could do to really get individuals to focus on to focus very carefully on the 501 3C status that the institution has so my view would be not to get rid of it my view would be to alter the structural incentives and you know I really care about ethical behavior, but you can make the high road a lot easier to make the low road a lot more hazardous. So I would seek strengthening regulation and increasing personal exposure and personal liability for leadership to these institutions that's my own though. Keeping in mind that the boards of most of these are nonprofits are not paid. They're volunteer. They're not starting to be paid at most of them are unpaid positions. But yeah, you know, you can certainly try to have some aspect of some minimum. I just get worried I mean when you can easily get all blocked down to some legal, you know, definition of what's appropriate for the behavior that goes on lawsuits for decades so you know I'm not sure that helps either. I, you know, frankly, the one of the most effective devices I found for getting people organizations to behave more terribly is the media and helping them write the story and getting the local pressure up, and then finally things start to change. And number of positions also in the chat, which I want to make sure that we have time to address a few of them but Jonathan you wanted to jump in I think. Yeah just to respond to your name necessarily be the board it could be the you know the, the institutional leadership itself but lots of people acquire board membership to pad CDs, and to enhance their social status. And if those positions came with real responsibility, we'd end up with a lot less CV padding and a lot more engaged board membership might be. So I'm thinking a little bit about there are a bunch of different types of questions in the chat and one of them actually was kind of brought up a few times which brings us back to the survey results. And in particular, the different populations that perceive ownership status as relevant and prefer nonprofits. So, one of the questions really focuses in on the medicaid the population and the fact that they do perceive ownership status as highly relevant. And I'm actually asking, you know, is, is that perception right that perhaps they would get better care in nonprofit or public places, aligned with real world data, and also more broadly what we to make of the increased sensitivity to hospital ownership status among the most marginalized populations in our society, especially in light of what Nancy has shared with us which is that maybe that our ship status doesn't align with a different type of organizational behavior. That's open to anyone. I'll just say learn if you want to start us. I was just pulling up somewhere granular data for you but you're absolutely right. Among the people who think that ownership status is relevant. I think they're really two constituencies and we're trying to assess these out clearly empirically but there is the group that is on medicaid, lower health literacy and lower education, right so that less than high school group, high trouble understanding health information medicaid, they're very sensitive to ownership status. I don't think they're actually the group carrying the torch for nonprofits, I think they're very sensitive in the way Nancy suggested where they prefer public hospitals. There's another group in the relevance bucket that is kind of, I like to always say like the you and me, relatively healthy, well insured, well educated we have the luxury of knowing where we want to go and making an informed choice. But that choice is not necessarily because, oh if I go to the wrong hospital I won't get care I'll be discriminated against it's because we have some kind of first principles preference. But first the group that I think is really carrying the torch for a preference for nonprofit hospitals. So, I can't show you that absolutely yet I can say in multivariate modeling the people who have a public preference are very clearly folks on medicaid and folks who have. Let me just make sure I'm getting this right as I say that loud. So low education and medicaid preference for public nonprofit is high education, high health status preference for the profit. So, you know, you start to see two different groups sessing out there, both think ownership status is relevant but they have different preferences. And there's been kind of a lot of discussion about how one might change the regulatory environment. In order to generate the kind of trustworthiness right that Jonathan was focusing us on among these hospitals that have, you know, in their name, the fact that they are not a profit. I'm curious actually, I wanted to bring in Charlotte or make a moderator who has had a question that a bit of a different level. Charlotte did you want to share your question. Sure. And people have definitely been building up to this question but you know there are changes that could be made in the regulatory environment hopefully with some ability to enforce and monitor and make public what happens. So I'm today, the leader of a nonprofit hospital, or a board member of a nonprofit hospital. Are there some takeaways from this discussion that you would want to suggest for the way I look at my behavior and my messaging and the culture of some of the people on our chat have talked about the culture within organizations and what a difference that is, you know, what are some implications for organizational behavior today. Yeah. I'm happy to take a first stab Jonathan unless you'd like to. That's my resident first. You go first. Yeah. So, I think what we've learned is. I have a great question why don't more hospitals that are nonprofits say they're nonprofit. And the results of the survey and the discussion today kind of shed some light on that because just saying you're a nonprofit doesn't communicate a whole lot necessarily. So you've got to go with Nancy's insight and urging. It's about behavior more than it is about status. And he has this great line in his old old papers that people trust nonprofits because they think what's in it for them to exploit me. And so to the extent that you want to behave to communicate something, I think it's not just I'm a nonprofit. It's that either there is no incentive for me as a hospital to exploit you, or probably more realistically. It's not like we're doing something, but we are sacrificing or we are foregoing that opportunity in the following ways to put your interest as a patient ahead of ours as an institution. And, you know, it would take more thought to come up with kind of a 10 point list about ways you could communicate that through your billing practices and through your patient care and through your registration forms. But I think that's the message that is at the heart of winning earned trustworthiness. It can be about behavior, even if we say and it makes us a little sad like oh nonprofits as a general category, don't act as charitably as we want them to. If you are someone sitting in one of these institutions, there are still plenty of opportunities for you to communicate honestly and productively about the way in which you put patient interest first. Thank you, Lauren. Are there Nancy or Jonathan. I was going to ask and say one of the examples of showing that you are community oriented rather than oriented was during COVID. Now a bunch of institutions just said well we can't find labor that's easy to pay. So we'll just shut the service down. And that include maternity and psychiatric and all kinds of community needed services that just got shut down because they say well we're having trouble attracting labor. Other places said we're going to go out and find contract nurses and pay them three times that we pay our normal nurses in order to keep the service open. That's a commitment to the community. We'll find a way to pay for it. We didn't have the money we find a way to pay for it. So there's all kinds of activities one can do. To show that the community is more important than making a positive the best bottom line, but you have to not go out of business for it. There has to be, you know, I think the feds have tried with the distribution of the cover money they didn't always get it right but you know that they are going to try to support these places to do the right thing and try to keep the services open. There are, there are things you can do but you know it's hard to regulate those kinds of things it's more over time what were the opportunities and then who took which ones. Perhaps some positive recognition. I was gonna say I think institutional culture is incredibly important. And I think, you know, it's, it's pretty clear when I talk to whatever I'm in a hospital and I talked to a nurse or janitor they understand the hidden curriculum that is being communicated to them in so many incredibly subtle ways. And so I think that's one really important place to begin. And I, I think you're absolutely right Nancy to contextualize it to put it in the context of what is already a deeply problematic healthcare system, right. No one, no one with any sense would devise it like this from the beginning if we were to start from scratch today it would not look the way it looks now. You're absolutely right that but then you have to figure out what is the what is the hidden curriculum within the institution, how can you improve messaging and you know when I started to look at for profit not for profit hospitals mission statements. They all look the same. They all look they've all been designed by the same kind of PR people. They all read the same way apart from in one case a very unfortunate icon. What was essentially meant to be doing good work for the community was represented as a fishing hook with a fish about to be caught by the hook. To me that looked like a strange icon for working in the community, but generally the text of these things all looks the same. So, less stuff, less worrying about what your website looks like, and more types time spent on the institutional culture and I'll just point out from my other work. You can stick notices on places and it doesn't affect the culture at all at Abu Ghraib. There were signs all over the detention interrogation center saying we comply with the Geneva conventions and the laws of war and detainees they're not to be abused and we've all seen the photograph showing abuse. So first place is attack the hidden curriculum and the subtle messaging within the institutions. And one other thing I'd say billing. So, this is my own theory if there are people in the room who can speak to it I'd love you to tell me if you think I'm a writer and if I'm wrong. So if I go somewhere I might get a bill of $15,000 for an MRI and the institution looks makes it look the not for profit makes it look like my health insurer has paid that and they're just looking for a few hundred for me. But of course that is not the case they have written off 13,000 my insurance company pays 2000 and I pay a few hundred. I think the reason why those are huge huge absurd bills is because we all know that in bankruptcy creditors usually only get a 10% return on what they're owed. And so they deliberately multiply all their bills by 10, knowing that those bills are going to make patients medically bankrupt. And if that is true, that is an abysmal strategy and needs to be rethought. Sam had his hand up but did you want to add to that quickly I know that we're running out of time, perhaps should conclude. I think we're a time. I'm going to invite Sam to share what he had to say in this chat will you wrap us up Charlotte. Thank you Kelsey and thank you. Many, many thanks to each of you on the panel, Lauren Nancy Jonathan, you've offered us a really nuanced nuanced understanding of some of the complexity of this area. Public understanding and reality of the value of the private nonprofit hospital today, and the implications of how people experience and think about that value. Thank you to the audience for your active participation and the insights and experience that you shared in the chat, which everyone has had the benefit of just been a very rich discussion. Lauren will be fascinated to see your study as when you have completed your analysis and are sharing it with the public. Thank you so much for providing this opportunity to have it discussed in this environment. What we care about is public policy and organizational practice here, and you've really offered implications for thinking how next steps might be for those participants in our health care market. For those who may have joined us late or would want to revisit this session, the program has been recorded and it will soon be available on the YouTube channel for the Harvard Center for bioethics. We'll be doing this again in the fall and program details will be announced on the center website. Meanwhile, have a good summer and made some of the discussion today be helpful as each of us goes about our practice and public participation. Thanks. Thanks everybody.