A Moral Choice: Economic Development or Lower Medical Charges?

cfphby James A. Bacon

Building on its plans to establish a Center for Personalized Health, Inova Health System is forging a partnership with George Mason University that will allow physicians, researchers and clinicians to work together on personalized medicine research, the two institutions announced yesterday. (See the Washington Business Journal article here.)

Inova will contribute $2.5 million in seed funding to the partnership and work with GMU to raise more money over the next few years. Much of the activity will take place in the former Exxon Mobil campus in Merrifield that Inova had previously purchased for $180 million. Inova’s plans also include a $250 million cancer institute, to be funded in part by a large donation by real estate mogul Dwight Schar. The larger vision is to build a health “ecosystem” devoted to the research, education and treatment of complex disease therapies tailored to an individual’s genetic make-up.

Meanwhile, GMU has unveiled a $40 million Advanced Biomedical Research building, rebranded its Prince William County location as its Science and Technology Campus, and started construction on a $73 million health sciences building.

These developments represent a welcome diversification of the Northern Virginia economy, which has been overly dependent upon defense, intelligence and homeland security spending by the federal government. Governor Terry McAuliffe understandably praised the latest announcement as a step in developing the “new economy” in Virginia. With characteristic enthusiasm, he said the new personalized-medicine campus could become a world leader. ” I love it because this agreement here is going to take us to the next level. … I want this facility to be the greatest in the globe.”

But the investment spree raises moral questions. For the most part, Inova Health System’s funding comes from its hospital operations. The not-for-profit Inova, which exercises near monopoly dominance in the Northern Virginia health care market, generated operating income of $218 million in 2014 on $2.7 billion in operating revenue. That’s a profit margin of about 8%, more than twice the profitability that non-profits normally need to maintain healthy operations. That translates into about $109 million in what one could classify as excess profit.

Unlike a for-profit company, Inova is not obligated to maximize profits. To the contrary, insofar as the company is exempt from taxes and has a community mission, one could argue that it is morally obligated to (a) reduce charges to patients afflicted by ever-escalating medical bills or (b) provide more care to low-income patients not covered by Medicaid.

To be sure, Inova does provide a significant volume of charity care. Its flagship hospital, Inova Fairfax Hospital, provided $151 million in 2014, according to Virginia Health Information. But the company’s high level of profitability suggests that it could do more.

Instead, Inova has chosen to plow its excess profit into economic development. I have no doubt that the personalized medicine initiative will benefit the Northern Virginia community in the long run by creating a new economic pillar in the region. The funds to do that are not likely to come from any other source. But it’s important to understand the trade-offs that Inova’s board is making here. It is extracting wealth from the community to bulk up the profits that grow the Inova empire. The people paying higher medical bills are not necessarily those who will benefit from the investment in the Center for Personalized Health.

Would I make the same decision if I served on the Inova board? Perhaps I would — I don’t know. But I’d like to hear all points of view presented. It’s a decision in which the public should have a voice.

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57 responses to “A Moral Choice: Economic Development or Lower Medical Charges?

  1. you know – you (at least I) end up wondering why some hospitals do well and some are on the edge of disaster and you wonder if it is because some serve a larger number of well off or a larger number of charity and that’s what makes them what they are.

    But one also might wonder if some of them of extremely well managed and delivery cost-effective care – and I’d not see that as a reason to penalize them or put more costs on them…

    I still think if you map the hospitals their status is going to reflect the status of the demographics of who they serve.

    So you’d expect a hospital with a top-notch reputation to do quite well in a region where the median income is near the highest in the nation (and ironic it’s a govt-centric economy!).

    and one would expect a southwestern hospital in a depressed area to not be profitable even if it was top notch.

    metrics about percent of charity and median income of clients would probably reveal and confirm the nexus.

    but , no – why should we penalize hospitals that do well if they are also serving their share of charity? I’d think we’d want to reward them and use them as models….

    and of course – we could ask why hospitals are supposed to figure out how to pay for the indigent in the first place. Why is that their responsibility?

  2. Merry Christmas, all! Mad Max was exhausting; so despite this provocative new topic, will wait until Boxing Day to have a say.

  3. Good Holidays to all!

  4. I think what is needed to be questioned is just how much $$$ are going to new buildings, new tech, administration, compared to people in direct patient care. I think charity care should be questioned as to where it goes to. I think we need to question why these non profits w/tax advantages need lobbyists or contribute to certain political campaigns. If memory serves, Sentara contributed $25K to the “electric choo choo” here. Now why should my money not go to physicians, nurses, and people who clean up after us instead of the “electric train” that many didn’t want their tax dollars wasted on in the Hampton Roads area?

    I wonder if it would be ok for me to publish excerpts of my letter sent to Sentara. Its been more than a year and I’ve yet to see an answer. Once you see where it talks about patient care and the like, you would see why I think Jim did an excellent article.

    The end part is very true about not wanting my ever rising health dollars paying for lobbyists crap compared to more physicians, nurses, etc. The whining on needing more money to train doctors/for residencies? If you have $25k to spend on a boondoggle, then how about hiring some more residents? They are more useful and I’d want my money for THAT rather than a Mayor’s “choo choo”.

  5. Merry Christmas to all. Seasons Greetings to you and yours.

  6. The world is changing including American health systems etc.
    And Northern Virginia with 2 million plus population is going to be a center of research and innovation.
    Inova has also joined with Aetna to offer a new health care insurance which looks very promising. It takes advantages of opportunities coming out of ObamaCare.
    And the Virginia Hospital Center in Alexandria has entered into a partnership with The Mayo Clinic in a major partnership which has enormous potential for health care in Northern Virginia and the larger DC community and perhaps all of Virginia. http://www.virginiahospitalcenter.com/aboutus/vhc/mayo_clinic_care_network.aspx
    Even with the economy of Virginia and particularly Northern Virginia (and Tidewater) slowing due to the federal government running out of money there are 2 million people in Nova with skills and advanced education which could continue to be a force for economic advancement in the 21st Century.
    But Virginia needs to do more to modernize our statewide economy too and that is a real challenge.

    • Is healthcare the way to go? Sentara has been called a “monopoly” here in Hampton Roads. I saw at least one item recently that indicated we pay higher prices for when those types of things happen. I received a letter recently for all Anthem insurance people that the single standalone hospital wasnt’ getting paid the rates other hospitals were and they were going to cut the contract unless they received the same rates.

      Get rid of the bloated admin from hospitals, no more non profit/not for profit with tax advantages where they sue the mess out of people, give $25K to lobbyists for a “choo choo” and then we’ll see a bit better about whether or not healthcare is worth it.

  7. Unbelievable. If this same thing were happening in Richmond Bacon would be releasing a combination of red, white and blue helium balloons and white turtle doves to celebrate the innovation and technological prowess of River City. But when it happens in NoVa it’s a dicey moral dilemma.

    Personalized medical care based on individual genetics holds the promise for vastly improved medical outcomes and far shorter hospital stays – for everyone. This reality utterly escapes Jim as he seethes with red hot rage over Northern Virginia moving forward. A newly opened meat pie store or microbrewery in Richmond is cause for great celebration while an effort to push the envelope of medicine in Fairfax County is worthy only of scorn.

    http://www.popsci.com/ibms-watson-prescribes-targeted-cancer-treatments

    • It might also be that this is a different scenario than what you listed. There are concerns about medicine. I’ve seen some not nice things come out of Duke. I’ve seen at least one MD go on to leading national groups and he apparently permanently disabled/crippled one person.

      Medicine, especially not for profit, what is the point? They get tax breaks, gives $$$$$ to bloated administration, rather than pay for professionals like the doctors, nurses, etc that is needed.

      • I think VN raises an interesting public policy question about the role & treatment of very large non-profits. I’d say there are at least two types that need to be looked at. The first is what, for lack of a better term, I will call “operating non-profits.” Those entities, such as Inova and private colleges, operate a “business” on a nonprofit basis. The other type is large foundations, such as the Ford Foundation and the Gates Foundation. Those entities generally fund other entities and projects.

        I think there is a role for the first type of entity. However, as VN suggests, their operations and compensation for high level administrators may need some type of review. Should a nonprofit pay a CEO a million dollars plus? Should such a nonprofit make contributions to advocacy groups? Should such entities be able to lobby and, if so, on what issues? If a for-profit hospital chain cannot deduct lobbying expenses related to national health care or taxes, what about a nonprofit hospital chain lobbying about the same?

        I am more concerned, however, about nonprofit entities that hold massive amounts of money and fund other entities or issues. The big nonprofit, private foundations. Why do we permit Bill Gates, for example, to pursue his interests on a tax-exempt basis through his foundation? And even more, why do we do the same for c. 68 years for the Ford Foundation? Do we want massive concentrations of wealth to live forever as nonprofits?

        • In total agreement with you on the foundations. I think I saw the same question come with the Zuckerberg/Chan’s foundation recently.

          Sentara funded at least $25K to go to the Tide/Light rail. I know they fund lobbyists. Now why in the world does a non profit need lobbyists to go to the State Medical Board? In terms of telehealth, when have they put their profits under patients?

          I think they should review not just the compensation but the number of levels of administration and why all these nurses are sitting in judgement over doctors? I think you could do better with a volunteer/part time paid position for patient panels and move these nurses back to floor work. I’ve seen way too many overworked nurses at every hospital. When I was in them, I found ways to keep them out of my room & do for myself. They’re not my lackeys and I need them for medication/bag changes, the real nursing stuff. Not whining to change my channel on the TV.

          A few people are needed yes, but I see more nurses on admin duty than floor nurses.

        • Excellent point –

          Corruption begins when “the Powers pulling the levers of Society” take command of the peoples’ language and in so doing change the definition of critically important words within that language to further gather, concentrate, and monopolize their own power and wealth.

          Hence, I suggest that Inova originally and still designated a “Non-Profit” by those Powers has now transformed itself into an extremely powerful for profit business monopoly.

          And that it is now a voracious government sanctioned monopoly at that. One in league with other monopolistic state sanctioned businesses that are still called institutions of higher education, and privileged members of the local real estate industry of Northern Virginia, all working hand in glove with the State of Virginia and Federal Government, and the powers of those governments to achieve their congruent goals, objectives and self interests in the name of the public interest. Yet another No. Virginia style Public Private Partnership.

          Some “Non-Profit”!

          • Reed Fawell 3rd

            One of the more informative articles on this subject is a Washington Post article published last February, nearly a year ago.

            See https://www.washingtonpost.com/business/capitalbusiness/inova-plans-giant-cancer-genomics-medicine-complex-in-fairfax/2015/02/06/8c09d40a-ad61-11e4-9c91-e9d2f9fde644_story.html

            Note the reference to the US President’s policy on these projects per his state of the Union Message. Note the Governor’s statement that this project would and should be privately funded. I believe I read or heard in a very recent public statement that the state of Virginia had or will contribute $16 million to the deal. If so, Why?

            And were or are any funds paid into George Mason and Inova by students or patients at either institutions being used here for this project. If so, why? And are any other taxpayer funds or tolls a part of the funding of this project? If so, why?

            Why does this project have to front on the most congested strip of Interstate Highway in the entire United States? An interstate that is critical the health and function of the entire DC region, and north south traffic up and down the east Coast, a highway that is already in near total failure much of the time, why put this project on top of that failed highway?

            Why should not the people of Northern Virginia demand now that every new project in Northern Virginia be “Traffic Neutral.” Or better yet that any such project “eat more than its own traffic” like downtown Arlington County from Ballston to the Courthouse has been doing now for three decades. Why not? There is no reason why this cannot be done, and should not be done.

        • “Should a nonprofit pay a CEO a million dollars plus?”

          At $2.7B in annual revenue Inova would be about #800 on the Fortune 1000.

          Health care is an immensely complicated business in the United States with mountains of regulation and a constant torrent of technological change.

          What compensation would you think appropriate for Innova’s CEO?

          • But Inova is not on the Fortune 500. It’s a nonprofit.

            I’d say $500,000 is reasonable compensation for a nonprofit CEO.

            Would Inova be unable to attract talented candidates if it paid $500,000?

          • I bet there would be a load of people willing to do the job for that, prove themselves. I think take down some of the other “benefits” and see what goes. Doctors do a lot more studying for less pay than that. Work quite a bit also.

        • Charitable donations should fall under the same tax law as estates. Why should Mark Zuckerberg or Bill Gates or Warren Buffet be able to legally avoid billions in estate taxes so they can establish parallel government agencies (called foundations) to pad their egos? People should have a lifetime allowance of $5m in charitable contributions. After that, the donor should have to pay estate taxes before sending any more cash to charities.

          Yet another example of how the elite and their mouthpieces in politics overwhelm the average citizen.

    • Couldn’t agree more, DonR. This should be celebrated. It’s an enormous step forward for a major NoVa economic engine.

  8. Speaking of education and $$$:

    http://www.dailyfinance.com/2012/03/26/surprising-job-that-gets-many-americans-into-the-millionaire-clu/

    But while managers are tops on the list, accounting for 17% of households with $1 million to $5 million in net assets excluding their primary residence, educators are close behind with 12% of the millionaire pie, according to the report.

  9. Hate to be the Gringe….
    But first. Congrats to Reed on new grandchild.

    As for the Baconanalysis, I am puzzled on several fronts.
    (1) He seems to be making a play that somehow Inova shouldn’t be making a play into research. Am I wrong? Or is he still taking a riff off of The TJ Public Policy Institute and its lobbyist-funded campaign against COPN and Medicaid expansion?

    (2) As Larry the G points out, why is it such a surprise that Inova has bucks. Given the disposable income rates of the environs, how can it not?

    (3) Speaking of bucks, the bucks Jim describes for this are small greenbacks. Instead of thinking in parochial Virginia terms, he should consider what else is in the greater DC region — namely Johns Hopkins. Maybe Jim doesn’t remember, but he has a master’s in African studies from the very same. The other top places are (besides Maryland), Boston, Texas, Cleveland, California. And of, I forgot, Maryland has NIH.
    (4) Why is Jim so concerned about getting medical research away from the federal teat? Big Pharma demands Big Bucks for Big Research. Thank God we have some government spending in there.
    (5) And while Jim is playing his free capitalism Christmas Carol, maybe he should remember what happened to Mr. Shkrelic of Turing Pharmaceuticals whose hedge fund buys made a needed medicine go form $13.50 a tab to $750. Last I saw, he was doing the perp walk in handcuffs.
    (6) And the way things are going around the world, maybe it’s time to pump more fed bucks into NOVA and what it is good at — defense. Can anyone spell ISIS? Why not admit that Virginia is the biggest beneficiary of John Maynard Keynes? Just trying to be honest.

    Magic of the market, Jim?

  10. I think I’d have to know more about how some hospitals are for-profit, some non-profit and some charity… rather than just focusing on one or two high-end ones.

    and even then – I’m not sure I’d want the govt setting salaries for anyone other than employees of the govt – that’s a wrong-headed idea.

    Finally – when we talk about COPN – again – I’d like to see a map showing where there are problems that are said to be caused by a lack of competition.

    This issue , along with others, get driven by sound-bite concepts as opposed to deeper understanding of the data and facts.

    we find one or two examples then we proceed to believe they explain an entire industry.

    there are hospitals in Va on the edge of financial disaster.. and yet we ignore why they are and focus on ones like Innova..

    my understanding is that not all hospitals offer all services and some hospitals do not offer services that are not profitable – that’s how they “turn away” charity care and how that, in turn plugs and play with insurance reimbursements and Medicare.

    so that’s another data point that should be considered. when you look at ALL hospitals – is the percentage of charity care different and if so , why?

    the one underlying theme I get out of this – is just how little most folks know about how health care is conducted in this country – and I include myself in that assessment…

    for instance, if you ask most folks how Obamacare and the Medicaid Expansion are funded – they not only don’t know – they assume things that are not true – egged on by those who purposely propagandize and misinform.

    if you’d ask where COPN laws actually increase prices – in Va or compare Va to states without COPN – where is that data?

    and why – would private insurance and Medicare pay more for an x-ray in one place than another rather than set a floor value nationwide based on what the unit and it’s operation actually cost?

    so many things that so many of us do not know – yet we draw conclusions…so quickly and easily

  11. here’s a concept worth exploring – whether or not a hospital offers certain services – and why or why not…

    “Making Profits And Providing Care: Comparing Nonprofit, For-Profit, And Government Hospitals”

    http://content.healthaffairs.org/content/24/3/790.full

    and interesting NYT – ” Benefits Questioned in Tax Breaks for Nonprofit Hospitals”

    ” The billions of dollars in tax breaks granted to the nation’s nonprofit hospitals are being challenged by regulators and politicians as cities still reeling from the recession watch cash-rich medical centers expand.

    Hospitals, among the largest landowners in many communities, are often designated as nonprofits, allowing them to benefit from state and federal tax breaks for providing “charity care and community benefit.” The exemptions collectively amount to more than $12 billion annually, health economists say.

    Now, provisions of the Affordable Care Act, along with Internal Revenue Service reporting requirements imposed in recent years, are revealing how much medical centers give back to their communities. And many health experts have found them wanting.

    “You should get close to the value of tax exemption in community benefit,” said Paula Song, professor of health services organization at Ohio State University. “I think you’ll find most hospitals aren’t providing that.”

    A study this year in The New England Journal of Medicine found that hospitals spent an average of 7.5 percent of their operating costs on charity care and community benefit, based on filings the I.R.S.”

    • I had posted (I think) before questions about what is included in that “charity care”. It could be amounts they haven’t collected yet from people, with or without insurance because they have provided care but its not been paid for.

      You have to read the fine print.

      If they can afford golden parachutes and the like for upper management, they can afford to provide more charity work. They’re taking from the haves (people with insurance) to pay for lawyers, grand pianos and waterfalls in the entry ways, and not using it for direct patient care (floor nurses, not admin nurses), and mostly for the haves too much (upper management).

    • Professor Song’s target seems to be a reasonable staring point for discussion and analysis. But, at the same time, a nonprofit hospital might provide other valuable community benefits beyond charity care that should be considered in evaluating whether the real estate tax breaks benefit the community.

  12. I think it’s a bit ironic that the required better specificity about what hospitals are claiming as charity care and community benefits is a provision of ObamaCare.

    I still do not think the govt has any business specifying compensation for any occupation that is not a govt employee. And in health care -you want the most innovative and knowledgeable people involved in running those systems – and should reward them enough to attract people who do produce.

    I’m AM in favor of full disclosure of what is claimed as charity care and community benefits – and penalties for failure to perform.

    more than that – we need to focus on reducing the costs of charity care that are caused by not getting regular care and basic cancer and diabetes and other screening.. so that disease is managed not left to fester until it reaches catastrophic stages – including costs.

    I note – that as the GOP in Richmond continues to run their mouth about Medicaid Expansion – that this is going on:

    ” Virginia eyes federal funds to help Medicaid’s costliest patients”

    Virginia wants to tap $1 billion from a federal pool of money – and put up a similar sum itself – to change the way Medicaid handles the few thousand Virginians who account for more than half of the program’s costs.”

    http://www.dailypress.com/news/dp-nws-medicaid-dsrip-20151215-story.html

    such hypocrisy!

    why isn’t our goal to start with to reduce charity care costs – instead of
    going after CEOs or fighting Obamacare?

    all the problems we have – that we need to address – and it’s still all about ideology – and not solutions.

    • I don’t disagree with Larry’s comment that the government should not be setting private sector salaries. But the precedent has been set for more than 20 years limiting the tax deductibility for compensation for high level executives. While I don’t think that was a good idea – especially since it ignores compensation paid to athletes, actors, and other entertainers, it would not be unreasonable to condition tax exempt status on maintaining some limits on executive compensation. I know a number of states prohibit any state funding of nonprofits that have very high levels of executive compensation. If you don’t like the rules, become a taxable entity.

    • “I still do not think the govt has any business specifying compensation for any occupation that is not a govt employee. And in health care -you want the most innovative and knowledgeable people involved in running those systems – and should reward them enough to attract people who do produce.”

      If you take tax breaks, then you basically become like someone on the govt. handout. The govt. gets to dictate. If you become where you are causing such a money drag on the economy, expect to get the govt. nosying in your backyard.

      “more than that – we need to focus on reducing the costs of charity care that are caused by not getting regular care and basic cancer and diabetes and other screening.. so that disease is managed not left to fester until it reaches catastrophic stages – including costs.”

      Lifestyle alone would help change that issue. If you fix that, then you don’t need a ton of preventative care. If you look at bariatric surgery, many lose diabetes, heart problems, and the like, and get more exercise. It is preventable but it has to be worked at. How about Hep C? Drugs, intimate contact, tats, all put you at risk. Some of this we can manage ourselves.

  13. I’d also add that I don’t think younger people think like this any longer. Most people that I know in Gen X and Gen Y simply don’t conceive of the world in these terms. They don’t say, “Oh, well X is ‘public sector’ or Y is ‘private sector’ or Z is ‘non-profit’.” I’d bet that 75% of them would think this is a good development for NoVa and Virginia They have a much more practical way of viewing the world. Both political parties don’t get this, but I think the GOP is in real danger of getting clobbered due to it. Gens X and Y probably do favor “charters” for poor-performing school systems and probably believe, in general, that market incentives produce a better standard of living in the long run. But they do not get caught up in ivory tower ideology like today’s GOP. If a gov’t program produces good results, they’re fine with it. If a non-profit is really playing a key role in innovation (even in the non-profit sees economic benefit) they’re fine with it. If universities are driving R&D, they’re fine with it.

    In my experience, the D’s are a little more conducive to this. Whereas today’s R’s are still caught in a Cold War “state v. private” mindset that seems anachronistic to most Gen Xers and Yers.

    • I agree with your characterization of the symptoms. But the issues transcend the politics of the day, although politicians of every age take advantage of the lack of experience and idealism of youth, and their lack of an education in how human nature works. This is quite typical of any age. It’s common as mud. Typically it takes a tragedy or tragic age to teach hard lessons well learned. The Federalists Papers, The Iliad, Thucydides, Cicero, the Greek Tragedies, Augustine, Dante, Shakespeare, to name a few, never go out of date. The Gen X and Y “much more practical way of viewing the world” will prove a Fool’s Errand. That you can count on.

      • One example saying the same things in a different way:

        “Anyone who reads history at all knows that the passionate and powerful convictions of one century usually seem absurd, extraordinary, to the next. There is no epoch in history that seems to us as it must have to the people who lived through it. What we live through, in any age, is the effect on us of mass emotions and of social conditions from which from which it is impossible to detach ourselves. Often the mass emotions are those that seem the noblest, best and most beautiful. And yet, inside a year, five years, a decade, five decades, people will be asking, “How could they have believed that?” because events will have taken place that will have banished the said mass emotions to the dustbin of history.

        People of my age have lived through several such violent reversals. I will mention just one. During the Second World War, from the moment the Soviet Union was invaded by Hitler and became an ally of the democracies, that country was affectionately regarded in popular opinion. Stalin was Uncle Joe, the ordinary chaps friend, Russia was the land of the brave, liberty loving heroes, and Communism was in interesting manifestation of popular will that we should copy. All this went on for four years and then suddenly, almost overnight, it went into the reverse. All these attitudes became wrong-headed, treasonable, a threat to everybody. People who had been chatting on about Uncle Joe, suddenly, just as if all that had never happened, were using slogans of the cold war. One extreme, sentimental and silly bred by wartime necessities, was replaced by another extreme, unreasoning and silly.

        To have lived though such a reversal once is enough to make you critical for ever afterwards of current popular attitudes.”

        From Doris Lessing, Prisons We Choose to Live Inside.

        Or, for another example, consider the large numbers of well educated British and American citizens who were big fans of the new German Reich government (that replaced the Weimar Republic) in the 1930’s because suddenly everything in the nation under the German Reich began to work so well again: like all those superhighways (autobahns) that got built, and all those new trains that ran exactly on time.

  14. can’t figure out if folks are talking about tax-exempt for the hospital or for the compensation paid to executives.

    but tax exempt for the hospital is easy. they can exempt only if they provide charitable care in the amount of the claimed exempted.

    In other words -no exemptions unless you can show that money went for charity.

    then how much to pay for executives is their business not the govt.

    this is entirely separate from anything else they do but be aware that some hospitals choose to not offer services that are not profitable in the first place.

    and again – when you leave it up to the hospitals to figure out how to pay for charity care – that probably should be the responsibility of the state to begin with – why then try to set rules for how they do it?

    all we are really doing is pushing responsibility for charity care – on the providers – who will transfer that cost to whoever they can – regardless of whether it is fair or makes sense ; that’s what you get when you push those costs on others – to begin with.

    Whether it comes to education or health care – the state waits for hand-outs from the Feds – then complains about the strings attached to the hand-outs.

    If the state was truly responsible – it would not be waiting on the Feds in the first place.

    it would have it’s own plans – independent of the Feds…

    • Tax exemption for the hospital. What people are saying is that the charity care provided is not worth as much as the tax write offs they are getting and the use of the money for other purposes than health care alone, nor should they be lobbying and the like unless they are true profit corporations.
      They could be providing the $$$$ for residency positions, instead of asking for the billions they already soak the govt. for. They don’t. Why not? If they have war chests of millions of dollars, then there are residencies that newly minted doctors need. Stop asking the govt. to do it and use the tax breaks to pay for the doctors.
      When it becomes where people can’t afford care because of the millions going to execs, baby grand pianos, then yes, it is time the govt. stepped in. if they can afford huge screen TV’s, etc. but don’t pay for nurses, remove the tax breaks. They are there to provide health care not entertainment and things that do NOT benefit healthcare. That means direct patient care.

      What I said could be done within hospitals and no state or federal involvement is needed. They are just going to ask until they break the bank like the banks did. Or should I say taxpayers backs?

      • Very well said.

      • There certainly needs to be a proper accounting of the charity tax breaks but I just don’t see that as any different than many other tax breaks in the code that are taken advantage of – including charitable donations by individuals.

        and I do not think it has much to do with addressing the more profound problem of people who do not have insurance that rely on financially-stressed hospitals serving the more economically distressed areas and geography of Va.

        that’s why I keep advocating that we use a map to show the hospitals that are “rich” as well as the ones that are financially stressed – to get a more concise picture.

        going after the richer hospitals is not going to address the real issue.

        • I’m sorry, maybe I and or others are not explaining it well enough.

          Would you think it right to claim a tax advantage, saying you gave charity care & deserved a break for it, if you claimed money that insured people had as their share of the deductible but hadn’t paid it yet? How about debt that you hadn’t collected, but hadn’t gotten a garnishment order on? You’d be recouping all the money, or probably about 90% of it, but you claimed & got a tax break on it?
          What happens if you are sitting on prime area property where tax strapped govts need the money? Do you think it helps to have the shrinking middle class try to pay for it? The strapped lower class who spends their $$$ on necessities? Or a billion dollar corporation that has millions/billions in the bank?
          Do you believe in tax breaks for churches? Not all churches provide the charity like my church & others do. Its in the form of food (I did over 100 pounds of food alone this year). Buying items like peanut butter, toothpaste, toilet paper, & giving them to the church, which is then given free to the needy. I get nothing back from it. I pay taxes on my property, etc. I don’t sit on prime land area.
          How many individual people are needed to make up for the millions of dollars in taxes that a taxed healthcare system would get?
          If you had taxes coming in from those healthcare systems, that could be shared with the financially strapped ones. They are competing against them, consolidating, exactly like the monopoly juggernauts in the robber baron era.
          http://www.propublica.org/getinvolved/item/when-doctors-feel-pain-after-a-medical-mistake
          That bad doctors, bad pastors and bad cops exist is part of the human condition; but it is entirely different when institutions and employees facilitate behavior that profits from the preventable injuries and death of 2-4 million Americans annually. Unlike churches and police departments, the healthcare and drug industries have successfully lobbied (e.g. bribed) the legislative and executive branches into indemnifying them when they are caught engaging in criminal behavior.
          http://time.com/money/4159131/hospital-prices-competition-monopoly/
          Bad news if your region is served by one hospital.
          A new survey of hospital prices across the United States found massive price hikes in markets in which one hospital enjoys a monopoly.

          Does that help or do you need more?

        • “Going after the richer hospitals is not going to address the real issue.”

          I’ll let VN speak for herself, but I don’t advocate “going after” the richer hospitals. I do think there needs to be a serious conversation — which has been totally lacking heretofore — about the role of not-for-profit hospital systems in Virginia. These hospitals do receive hundreds of millions of dollars worth of tax benefits, as they have for decades, on the grounds that they provide a valuable social service.

          What is that social service? When community hospitals were originally established, their mission was to extend medical care to geographic regions that did not have ready access to it. There was a widespread social consensus that this was a worthy goal. Communities mobilized to start-up and maintain these hospitals. Over the decades, the mission has morphed. Now monopolistic health care systems like Inova and Carilion, which consolidated their local health care sectors on the grounds of cutting costs and keeping health care affordable, are accumulating substantial profits and using the revenue to underwrite economic development.

          Economic development is a worthy goal, nobody disputes that. But we’re seeing mission creep on a massive scale, and no one is remarking upon it. No one is asking, who’s paying for all this? No one is asking whether the not-for-profits could be charging less for their medical services (while still maintaining a profit), and passing the savings on to patients and the employers who pay for their private health-care insurance.

          I’m not saying that hospitals should not make these investments. I’m just saying that we need a thorough airing of the issues. But some who frequent this blog seem to think that we should all just shut up and look the other way.

          (By the way, Don the Ripper, your criticism of my post is totally unfounded — a classic case of selective memory! I’ve called Richmond-area hospitals to task for their huge profits as well. I’ve questioned VCU Health Systems’ refusal to cooperate in the construction of an independent, regionally supported children’s hospital, to be built in part with $300 million in private philanthropy, and its decision to invest its swollen profits into its own children’s hospital.)

          • Not exactly on point, but, IMO, still instructive. The McLean Community Center (MCC) is county-owned and operated, funded by revenues from rents, classes and events, as well as a special real estate tax levied within a special tax district. As a government agency, it needs revenues that slightly exceed anticipated expenses.

            While the County retains ultimate control, the day to day operations are managed by county staff as advised by a citizens board. People are elected by local residents and confirmed by the BoS.

            For years, the local board built up a significant surplus, well beyond what was necessary to support maintenance, etc., and to build a reserve for expanding the facilities. Indeed, some developers wanted to use the reserve to construct an MCC facility in “downtown” McLean as a springboard for more real estate development and private profits. Community opposition to this type of welfare killed the downtown expansion. Taxpayer pressure forced out the surplus builders from the local board and caused a slight refund of the excess taxes in the form of lower tax rates. Finally, community consensus for a renovation and expansion of the MCC caused the local board and BoS to agree on the project using only the built up reserves.

            I have no trouble with a government agency or nonprofit building up reasonable reserves for capital projects or even expansion, either physical plant or new programs if consistent with the entity’s mission. But it seems wrong for either a government agency or a nonprofit to accumulate very large financial reserves. I think this principle should also apply to big nonprofit medical chains.

          • Reed Fawell 3rd

            Jim Bacon says. “I’m not saying that hospitals should not make these investments. I’m just saying that we need a thorough airing of the issues. But some who frequent this blog seem to think that we should all just shut up and look the other way.”

            V N says … How many individual people are needed to make up for the millions of dollars in taxes that a taxed healthcare system would get? … Bad news if your region is served by one hospital. A new survey of hospital prices across the United States found massive price hikes in markets in which one hospital enjoys a monopoly …”

            Thanks to the both of you. I could not agree more. In fact I sense the possibility of an odor not dissimilar to what was going on in and around Dulles Airport during the first decade of 21st century.

            For example, the sudden need to massive tolls and toll road increases to serve private interests disguised as the public interest, namely to cure transportation problems and enhance economic development, that in fact turned out only to make matters far worse.

            In addition, there seems to be a pattern here. A “non profit or public private affair” seeking an ever more monopolistic market share by promises of building a greatly hyped World Class Crown Jewell, new public facilities that will make parts of N. Virginia the King of the Region, and indeed a King of the World with exploding growth of all kinds in a gridlock location. All paid for on the backs on long suffering commuters and users of tax advantaged public service facilities (Here a hospital & public university is arguable being used as a political, financial, and research juggernaut in league with government for private advantage).

            Note, for example that Inova has been reported to have a 70% market share in its own “area” and works to expand that 70% both there and also into outside markets. Note to Duke’s similar facility in NC. Note also alleged development of Exxon site per recent Washington Business Journel article dated Sept. 29, 2015 entitled”

            “Exclusive: Inova’s Vision for Exxon Mobil Campus includes Restaurants, Retail, Lots of Research.” Hotels are mentioned elsewhere. Here is how the Fairfax County Economic Development Authority characterizes the deal:

            “Fairfax County-based Inova Health System announced today that it will take over the ExxonMobil headquarters building in the Merrifield area of the county to house the Inova Center for Personalized Health. The center will make Fairfax County “a community known worldwide for genomic science,” said Gerald L. Gordon, Ph.D., president and CEO of the Fairfax County Economic Development Authority (FCEDA).

            Gordon attended an event today at Inova Fairfax Hospital where hospital system officials announced creation of the center. The event also featured Gov. Terry McAuliffe and Fairfax County Board of Supervisors Chairman Sharon Bulova as well as leaders from Inova and Exxon Mobil. Inova CEO Knox Singleton announced that the Peterson Family Foundation will donate $10 million for the initiative.

            “The enormity of this announcement is almost indescribable,” Gordon said. “This campus will make Fairfax County a hub for world-class research and the commercialization of ground-breaking discoveries. New companies will grow as a result and more world-class researchers and businesses will want to be here.”

            The Inova Center for Personalized Health will have three goals:

            Create the world’s leading center for translational cancer research and patient care based on genomic science and individualized therapy;
            Create a leading center of nationally recognized biotech researchers developing new tests, therapy and population health processes based on genomic science and bioinformatics; and,
            Stimulate collaboration of life-science companies with world-class researchers leading to the expansion of the life-science economy in Virginia and the Washington, D.C., area.

            Gordon noted that the center will dramatically accelerate the FCEDA’s goal of further diversifying the economic base of the county. “We’ve been working to attract, retain, and grow the county’s non- government contracting economy for several years. This announcement places Fairfax County in a leadership position in the growth of the nascent industry of translational medicine,” he said.

            The center will be based in a landmark building, near the Capital Beltway interchange with Arlington Boulevard (U.S. Route 50) that has served as the “downstream headquarters” of ExxonMobil since 1999 and previously was the corporate headquarters of Mobil Corp. ExxonMobil announced in 2013 that it would consolidate its headquarters functions in a new campus in the Houston area.

            “Mobil Oil’s decision to locate its headquarters here in the 1980s put Fairfax County on the map as a corporate headquarters location, and Inova’s decision is just as momentous, heralding an exciting new economy for the county,” Gordon said.

            Time magazine called Fairfax County “one of the great economic success stories of our time.” Business growth and innovation helps Fairfax County fund the nation’s top-rated school system and other public services that contribute to the quality of life of residents. Fairfax County offers businesses a state-of-the-art telecommunications infrastructure, access to global markets through Washington Dulles International Airport, a vibrant investment capital community and a highly skilled, well-educated workforce.

            The award-winning Fairfax County Economic Development Authority promotes Fairfax County as a business and technology center. The FCEDA offers site location and business development assistance, and connections with county and state government agencies, to help companies locate and expand in Fairfax County. In addition to its headquarters in Tysons Corner, Fairfax County’s largest business district, the FCEDA maintains marketing offices in seven important global business centers: Bangalore, Munich, London, Los Angeles, Seoul and Tel Aviv. – See more at: http://www.fairfaxcountyeda.org/pressrelease/fceda%E2%80%99s-gordon-inova-initiative-will-make-fairfax-county-%E2%80%9C-community-known worldwide#sthash.TtXHE7J6.dpuf

            No one objects to health. No one objects to economic development. No one objects of Higher education. The questions instead hang between the lip and the cup, such as:

            – how, why, where, and when?

            – Who pays, who benefits, who gets hurt, who gets the shaft, what are trade offs, and what are the downsides, including such things as building something cannot work because no one can get to it?

            There is a whole lot going on here. There are many questions that need be asked, answered, and properly and fairly dealt with before vast monies are spent on the basis of promises and grand visions, particularly in Northern Virginia were thus dog and pony show has been around the track many times before and too often don’t pan out except for a very few at the expense of everyone else. It’s happened so often before, maybe this time it can be done right, in ways that cure old problems, benefits everyone, and does both in ways that last a very long. Given the way this latest gambit has gotten off the ground into the public light of day, I fear this is nothing more than the same tired old game.

          • I’m referring to all hospitals, using one as an example. Other than that, excellent points Mr. Bacon.

  15. what is the point of going after the richer hospitals

    .. in the CONTEXT of the costs of health care for those than don’t have it …

    … especially if they don’t live near the richer hospitals and rely on hospitals that are not rich for their access to care?

    haven’t folks conflated this six ways from Sunday and to what purpose?

    the Title: ” A Moral Choice: Economic Development or Lower Medical Charges?”

    how does this relate to those who don’t have access to heath care and don’t live anywhere near the “profitable” non-profit hospitals?

    if you actually had a list of the rich hospitals and the actual number of folks not having insurance, and the charity numbers -you might have some sort of argument but what you’ve done is totally screwed up any real meaning to any of this – ….

    rich hospitals invariable serve rich demographic neighborhoods…

    what exactly would you have them do with their “booty” and how would that do anything at all to help the hospitals that have large populations of charity care and so unprofitable that they are on the edge of financial disaster…

    what’s your relevant point?

    • The issue is are they really using the non profit status to accumulate wealth in the hands of a few at the expense of those who have and aren’t giving it to those in need.

  16. re: ” These hospitals do receive hundreds of millions of dollars worth of tax benefits, as they have for decades, on the grounds that they provide a valuable social service.

    What is that social service? When community hospitals were originally established, their mission was to extend medical care to geographic regions that did not have ready access to it.”

    Jim – where did you get this?

    what are community hospitals and can you show me how they were sited and charted as such -geographically?

    Could you draw a map of hospitals in Va and identify which ones are the ones that you say were designated as community hospitals with non profit status – so they could serve populations of underserved?

    could you just make a list of them – with relevant data showing how much in tax breaks they got, how many charity cases and the dollar value – and compare that to hospitals not so designated and without tax breaks?

    we have more than a billion dollars of uncompensated care in the state –
    http://hbp.vcu.edu/media/hbp/policybriefs/pdfs/VCU_DHBP_HUCC_WEB.pdf

    can you show how that allocates geographically and to what hospitals?

    what you and VR and other have focused on – is very non-specific – things – concepts… and then claimed that “profits” are not going to pay for charity care – as a general claim… but almost zero data to back it up beyond a couple of obviously rich hospitals located in rich demographic areas…

    so you’ve constructed this narrative which has a very slim slice of data and transformed it into : ” A Moral Choice: Economic Development or Lower Medical Charges?” as if this is an answer to folks without insurance and access to health care…. if we only took away these tax breaks – it would take care of the problem.

    I do not think you should “shut up” but I DO think this way of presenting issues is not exactly an honest approach.

    once again – we play the govt blame game – then from that – all kinds of things get tacked on – read the comments here… as if everything from bad breath to body odor is the fault of bad govt policies – on and on … to include folks who don’t have access to health care.

    I’m calling it the “kitchen sink govt blame game..”

    ya’ll don’t even know real numbers… you’re assuming things you don’t even have data for so we can play this silly blame game.

    geeze

    • I do believe I posted some items but here are a few:

      http://www.arbiternews.com/2014/04/08/why-nonprofits-are-the-most-profitable-hospitals-in-the-us/
      However, in reality U.S. nonprofit hospitals are extremely lucrative. At the same time, many fail to provide the valuable services for which they get preferential tax treatment.
      In the U.S. healthcare industry, being nonprofit is more lucrative than being for-profit.

      “The 2,900 nonprofit hospitals across the country, which are exempt from income taxes, actually end up averaging higher operating profit margins than the 1,000 for-profit hospitals after the for-profit’s income-tax obligations are deducted,” writes Steven Brill in his pioneering health exposé in Time Magazine. “In health care, being nonprofit produces more profit.”

      “Payment of excessive compensation to executives, managers, and administrators undermines the purposes of nonprofit corporations because it results in fewer funds being available for their charitable purposes,” concluded a 2013 study by the office of the attorney general in Sacramento, California. “It is often the case that the hospitals, hospital groups, and affiliated medical entities that pay the most excessive compensation also provide less charitable care than comparable institutions that pay reasonable compensation to their executives, managers, and administrators.”

      The issue is further complicated because the level of charity services provided varies widely between nonprofits.

      Moreover, nonprofits do not necessarily provide more charity care than for-profit hospitals. A Government Accountability Office (GAO) report concluded that while government hospitals devoted a substantially larger share of their operating expenses to charity care, the difference between nonprofit and for-profit hospitals was small.

      “For decades, being a hospital seemed sufficient justification for nonprofit status, but as medical services took on aspects of big business — aggressive bill collection tactics and six-figure pay for executives — the distinction between not-for-profit hospitals and their for-profit competitors blurred,” writes M.B. Pell in the Atlanta-Journal-Constitutional.

      While the federal government, through the IRS, sets several requirements for nonprofit hospitals to qualify for federal tax breaks, a large number of states do not have specific requirements to qualify for state tax breaks.

      However, much more needs to be done in terms of transparency in the healthcare industry.

      https://nonprofitquarterly.org/2013/12/18/debatable-how-nonprofit-are-nonprofit-hospitals/

      Hospitals can also take credit for hosting health fairs, operating some research labs and ‘donating’ their executives’ time to serve on local community boards.”

      The observation of John D. Colombo, a professor of tax law at the University of Illinois Urbana-Champaign, is very telling. “The standard nonprofit hospital doesn’t act like a charity any more than Microsoft does—they also give some stuff away for free,” Colombo said. “Hospitals’ primary purpose is to deliver high quality healthcare for a fee, and they’re good at that. But don’t try to tell me that’s charity. They price like a business. They make acquisitions like a business. They are businesses.”

      In the NPQ Newswire, there have been a number of articles in recent months on the decline, not the growth of charity care delivery by nonprofit hospitals and by “safety net” hospitals. Fearing challenges to their local property tax exemptions, nonprofit hospitals’ public relations arms are milking as much good press as they can about their community benefits.

      healthaffairs.org/blog/2013/06/11/hospital-community-benefit-expenditures-looking-behind-the-numbers/

      content.healthaffairs.org/content/24/3/790.full

      digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=1157&context=yjhple

      https://www.thelundreport.org/content/profit-hospitals-skimp-charity-care

      truecostofhealthcare.net/hospital_financial_analysis/

      https://100r.org/2014/04/nonprofit-hospitals-charity-pays/

      http://www.hilltopinstitute.org/publications/WhatAreHCBsTwoPager-February2013.pdf

      http://www.healthlaw.org/issues/health-care-reform/nonprofit-hospitals-and-community-benefitpdf
      There is strong evidence that many nonprofit hospitals do not operate in ways that are significantly different from those of hospitals that are operated as profit-generating enterprises.

      http://www.mass.gov/ago/doing-business-in-massachusetts/health-care/community-benefits.html

      http://www.rwjf.org/en/library/research/2012/10/what-s-new-with-community-benefit-.html

  17. re: ” Would you think it right to claim a tax advantage, saying you gave charity care & deserved a break for it, if you claimed money that insured people had as their share of the deductible but hadn’t paid it yet? How about debt that you hadn’t collected, but hadn’t gotten a garnishment order on? You’d be recouping all the money, or probably about 90% of it, but you claimed & got a tax break on it?”

    Whatever people are billed for – is a debt they owe – whether it’s covered wholly or partially by insurance, deductibles or the person has no insurance.

    the hospital bills for services rendered – as it should.

    if that hospital has configured itself to offer profitable services and to incorporate efficiencies – then it rightly should be able to further develop itself as an even more successful enterprise – perhaps aspiring to become another Mayo or Cleveland or MD Anderson – and in turn become a economic asset to the region around it.

    the rules by which they get to claim charity care and community benefits apply to all hospitals – including the ones that are forced to provide services that are not profitable and in turn put them at financial risk.

    I don’t think you can or should have rules per hospital. if someone thinks some class of claimed charity or community benefit is inappropriate -then fix it – but do it knowing that it affects all hospitals – not just the profitable ones.

    I just can’t see selecting out hospitals that are playing by the same rules as other hospitals and targeting them because they’ve figured out how to be more profitable.

    finally – doing that – just totally ignores the bigger problem of all the other hospitals that are not only not profitable but financially distressed because the region they serve has far higher numbers of folks who can’t pay and its the title of this blog:

    ” A Moral Choice: Economic Development or Lower Medical Charges?”

    that sort of implies that “fixing” the choice is to “fix” the for profit hospitals so that those in need can be better helped”.

    I think geography plays a huge role in this and you can do whatever you want – inappropriate and selective as it might be to the more profitable non-profits and not make a dent at all in the bigger problem of vast areas and regions of this state that are far worse off economically – both the people and their hospitals.

    so I don’t see how this helps … and at the same time it comes across as off target…

    • The point I was making is that these exemptions claimed for “charity care” are not truly charity care in the eyes of any one. Therefore they are acting like, and will do so, for profits in terms of what they’ll do to make a profit and put $$$ back in the hands of executives. Yes they may build, but are they building in areas that need it? They don’t want to serve rural areas, you don’t see any one building in those areas. Its only where there is a profit.

      The other point I am making is that if you are a non profit, you put into buildings, but where are you investing in *PEOPLE*? They are not hiring floor nurses, home health care nurses, etc. They run them nuts. So in terms of economic advantages, they are not doing what a non profit should in terms of supplying jobs for health care. How many layers of management do they need? I submit they only have $$$ to put into people or buildings, and they are building buildings but not making nursing schools or jobs for nurses. They are not putting $$$ into paying for residency positions they are whining about. People drive the economic engine.
      If you are also non profit, we are paying high prices compared to other countries and not seeing any benefit. Meaning there is crap in the system. If they run these docs and nurses ragged, rather than hiring more docs, creating more residency positions in needed areas like FP/GP/GInt, surgeons, etc. well they aren’t there to really be putting $$$ into their mission. Buildings go up and then the work is done, it is not permanent jobs.

      If their aspirations are to become like Mayo, then you have to spread out the campuses. Why not build in a slightly off rural area like Williamsburg, or around that? That is between 2 major areas and would help a rural area become more populated instead of the traffic congestion/override you have now in the DC area?

      I have only used Sentara as an example. I have used Chesapeake because they, as a single hospital, apparently were not getting dealt with fairly by insurance companies. If you give one in an area $$$, then share it all around, other wise we come up with monopolies and that is one of the main problems Sentara causes.

      Have you tried to get things fixed in the legislature? Taxes? Let me know and I’ll have you join in the fight.

      If it was and is about care, then why aren’t the big hospitals helping the smaller ones? Profit, profit, profit. They are a non profit for a reason, they act like for profits.

      • how do we know that it’s not charity care?

        when you say “they” do not want to serve rural areas – do you expect NoVa (or Hampton, Richmond) hospitals to become statewide hospitals ?

        and how do you know if they are investing in people or not – to the degree that they need to – to serve their clientele?

        One might presume that if they are doing well financially and they derive their money from services to customers that they are, in fact, resourcing people at the right levels; after all people are choosing to stay at their hospitals rather than go elsewhere.

        the underlying premise here (between the headline and sentiment in the comments) seems to be that because some hospitals in some geographic areas are successful and profitable that the use of those profits should not be decided by the folks who run the those enterprises – because they choose to not use them to help those who can’t afford health care.

        if I have phrased this wrong – please re-state it – to reflect what is really meant.

        remember – in all of Virginia – more than a billion dollars of uncompensated care is delivered by hospitals but if you “mapped” it out – it would not be uniformly distributed across all hospitals at all.

        there will be some hospitals whose natural service areas are going to have vastly different numbers of uninsured people and the hospitals themselves may choose to focus more on services that are profitable and less on services that are not.

        why are bigger, more profitable hospitals not “helping” the smaller ones?

        are we, should we – be expecting hospitals to be part of a statewide network – where some will subsidize others – by law?

        I’m not sure exactly what is being expected here but I think Jim kicked it off when he entitled the blog as if the actions of individual hospitals affected the plight of the uninsured in general.

        not the first time – we conflate issues here… but perhaps Jim SHOULD write another asking if we SHOULD make all hospitals part of a statewide network whose collective mission IS to help ALL Virginians who cannot afford health care…by spreading out “profits” – which would help to get a real focus on what was implied by this post”.

        Is the real sentiment here that hospitals operating as individual entities is not in the best interests of Virginians?

        • Charity care should be care already written off. Not money you haven’t been paid for services yet.

          Their mission is to serve healthcare to the public. They don’t want to expand in rural areas because it cuts down on profits. Not for profit means investing in healthcare, not healthcare to those who have it so you can accumulate more profits.

          When you have tons of admin and nurses can’t take breaks because they are short staffed, you are paying for bloat/bureacracy and not true healthcare to people, taking care of them.

          People don’t choose to stay at hospitals. Its in the insurance hands as to whether or not they do, otherwise its charity care or taken from those who have to pay for them.

          The underlying premise is correct. The idea is that you get profits and then help out those further out, etc. not try to expand the business just to accumulate profits. New Jersey has another area where they are getting hit with taxes because they act and behave no different than a for profit entity.

          The bigger hospitals are looking at bottom line profit, not on providing healthcare and streamlining ops to help those who don’t have. The whole idea is that you get tax breaks to help, not expand as a business and become a monopoly.

          Is the real sentiment here that hospitals operating as individual entities is not in the best interests of Virginians? Not for profit entities that are looking to use govt. influence to expand the business for restaurants, etc. are more like any other taxable business.

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