Healthcare Access and Economic Challenges at Shepherd Center

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Policy Research and Organizational Analysis Report LaAshlee N. Valentin Southern New Hampshire University IHP 620 Professor Ondo July 13, 2024

Introduction The organization of focus for my report is the Shepherd Center, a long term, non-profit care facility that specializes in providing research, treatment, and various physical rehabilitative services within the Atlanta area to individuals who have experienced spinal cord and or brain injuries, strokes, multiple sclerosis, spinal and or chronic pain, and miscellaneous neuromuscular conditions (Shepherd Center, 2024a) in addition to offering housing for patients family’s (Shepherd Center, 2023a). Though in Atlanta, patients they treat come from across the nation and abroad (NIDILRR, 2022). The facility treats over 700 individuals for in-patient care, over 200 day-program patients, and over 7000 individuals seeking outpatient services annually (Shepherd Center, 2024b). The Shepherd Center mission is to aide those with physical limitations in rebuilding their lives, establishing a sense of normalcy, regaining independence, and maintaining hope of recovery in a dignified manner, as well as being staunch advocates for injury awareness and mitigation, safety promotion, and societal inclusion (Shepherd Center, 2024b). The Shepherd Center is a long term, voluntary non-profit hospital offering both in- patient and outpatient clinical services with bed availability for a maximum of 152 individuals (Shepherd Center, 2024b). Based on a 2018 community health needs assessment and implementation plan published by The Shepherd Center, a majority of those they service have experienced a spinal or brain injury because of a vehicular or other form of non-recreational accident (Bennewith et al., 2018). Although The Shepherd Center does not provide data pertaining to when there is are increased inquiries for individuals to be accepted into the facility for rehabilitative services, according to the National Safety Council, a majority of non-fatal vehicular accidents resulting in injury, take place during the summer months with spikes during May, June, and July (NSC, 2024), which

could be attributed to increased vacation travel. Due to The Shepherd Center treating patients they treat come from across the nation and abroad (NIDILRR, 2022), requiring increased funding (Shepherd Center Foundation, 2024), and conducting structural expansion (Shepherd Center, 2021b, December 8) speaks volumes regarding how invaluable their services truly are, which will undoubtedly continue their revenue increases, as well as their required expenditures. In 2023 their full tax filing reported revenue of over 320 million and expenditures over 290 million, which included costs associated with staff salaries, standard treatments, medication, and technologically based treatment offered as indicated on Tax Form 990, Schedule D (Suozzo, 2024). Economic Disparities Healthcare facilities experiencing financial difficulty may be unable maintain quality of care, ensure patient safety, offer necessary services, and or avoid closure (Akinleye et al., 2019). Performing well financially correlates with better patient care experiences, however patient care is compromised as a hospital’s financial stability declines (Akinleye et al., 2019). When considering the financial health of hospital facilities, indicators measuring profitability, liquidity, and solvency are utilized to assess financial health (Akinleye et al., 2019). To make up for financial shortfalls, healthcare facilities may resort to employing questionable practices such as cost shifting and cream skimming, which impact services offered and pricing. Cost shifting is a concept utilized in opposition to affordable healthcare policies which provide balanced reimbursements and prevent assessment of facility fees (United States of Care, 2024). Healthcare entities argue that affordability policies force them to offset revenue losses by implementing cost shifts on privately insured patients (United States of Care, 2024). Higher

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reimbursements are justified offsetting low reimbursements obtained from Medicare and Medicaid (United States of Care, 2024). Hospitals charge different health plans different amounts for the same service even at the same time which is a form of price discrimination (Frakt, 2011). In cost shifting, if one entity pays less, another will pay more (Frakt, 2011). Cream skimming is the selection of patients based on characteristics that are not related to care increase profitability or enhance the reputation of a provider; this often results in patients that are not necessarily ill being selected (Friesner et al., 2009). Providers due have the right to refuse care under certain conditions, however refusal that is based on discrimination is unlawful (Friesner et al., 2009). Economically, cream-skimming implies that more restrictive healthcare plans offer lower premiums and attract healthier individuals, which increases the premiums of plans that offer enhanced coverages, ultimately reducing overall coverage and enrollment for comprehensive plans (Drakes et al., 2020). Adverse selection via methods such as cream skimming is a persistent associated with faulty risk measurement practices, preferred utilization of pricey providers, and prominent facilities offering top tier services and advanced technology to those deemed the sickest (Drakes et al., 2020). Practices such as cost-shifting and cream skimming are justified by those utilizing these methods due to low reimbursement rates received from Medicare and Medicaid. Low reimbursements have led to decreased provider participation within these systems, increases in acceptance of new patients with private insurance, and declines in Medicaid/Medicare new patient acceptance; Low participation facilitates inaccessibility of low-income patients (ACR.org, 2023). Medicare and Medicaid reimburse hospitals less than the associated care cost and their rates are non-negotiable (ACR.org, 2023). Medicare and Medicaid account for most

hospital utilization (ACR.org, 2023). If hospitals who heavily rely on these reimbursements cannot appeal to privately insured patients, this not only adversely affects them financially, but compromises both accessibility and quality of care. These reimbursement systems impact hospital budgets by requiring them to include more efficient, cost-effective services and treatments to lower spending which possibly results in service and resource limitations (Blunck et al., 2024), salary reductions, and staffing cuts making it difficult for them to provide enough care to compensate for the lowered reimbursements. Economic Theories Economic theories that are most useful when applied to the healthcare industry are resource health economics (allocation and efficiency), behavioral (purposeful and goal oriented), and product distribution (who will be able to access their services) (CDC, 2001). These are useful because they ensure funds are utilized in a meaningful way and that they are able to provide the services the patients need and expect, the organizational goals must be reflective of those of their patient’s, and due to the size of a facility you may be required to establish criteria to determine who would benefit from your services and if you offer the services an individual may require. Their funding is allocations go toward ensuring they employ the latest technologies and research techniques, facility upgrades and expansion, community initiatives, maintaining an environment that promotes family inclusion in the rehabilitative process, and employing the very best in their prospective fields (Bennewith et al., 2018). They do not have the facility space yet to accommodate the overwhelming demand for their services, however they subsidize care, and are increasing accessibility not only to those within the immediate community but to individuals out of state, which are all reflective of their mission (Bennewith et al., 2018). There are criteria that

must be met and a vetting process in place to ensure prospective patients will truly benefit (Shepherd Center, 2023b). Economic Principles Organizations utilize economic principles to guide strategic short-term and long-term decision-making Economic principles that are often applied to address issues within health and healthcare are scarcity, choice, efficiency, marginal analysis, opportunity cost, market failure, supply and demand, efficiency, markets and pricing, and competition (Henderson, 2018). Of these economic principles, the ones that play a key role in shaping the healthcare industry are choice, opportunity cost, scarcity, and the law of supply and demand (Henderson, 2018). A grasp of these concepts allows for increased efficiency pertaining to resource allocation, which in turn ensures scarce medical resources are utilized appropriately and are beneficial to the greatest number of individuals a healthcare entity services which is a positive impact (Parkin, 2017). A negative impact of applying these principles is the potential of healthcare entities to focus so heavily on cost effectiveness that they begin limiting, or denying high-cost treatments and or services to those they serve (Parkin, 2017). For healthcare organizations to find a balance between economic principles and the implications for human health, life, and mortality when making policy decisions and strategic plans, they must maintain a focus on patient centered care by ensuring that they provide each individual with optimal services regardless of the cost and when possible enact alternative methods that may be less costly, yet equally effective, create policies that promote health equity, affordability, and increased accessibility, and allowing patients to take a more proactive

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approach pertaining to their own health via education to enhance health literacy and increasing preventative health measures. For-Profit and Nonprofit For-profit organizations are typically owned/operated by private entities or corporations hospitals are typically owned by private entities or corporations, are required by law to require to pay federal, state, and or local income and or property taxes, generate profits for their stakeholders, acquire operational funding via investments/investors, payments/fees for their services, and various forms of reimbursements, and they also prioritize providing high revenue generating services (Popowitz, 2023). Non-profit organizations are typically owned/operated by charities, academic entities, or religious groups, are exempt from paying federal, state, and other local income and or property taxes, re-incest any profits they acquire into the areas/communities they service and provide services that benefit the community which result in smaller profit intake (Popowitz, 2023). Both entities also differ regarding the owner’s equity and organizational structure, as well as their overall goals and objectives (Broughel, 2023). Similarities both entities share is a requirement to report all revenue that exceeds operational cost and their ability to make a profit though the actual amounts are vastly different (Broughel, 2023). For-profits are equity maximization focused and base their decision making on increasing the value of the organization or company, while non-profits tend to be mission focused which inhibits them from being financially equitable (Broughel, 2023l). Possessing a non-profit status allows an organization to take advantage of benefits such as being exempt from sales, property, and income taxes (IRS, 2024a, March 29) to be considered a non-profit, an organization must showcase public and private interest devoid of the desire to

obtain commercial or monetary profits (IRS, 2019c). There are however guidelines that must adhered to in order to obtain and maintain this status such as being charitable, scientific, or religious, relinquishing profits back to the community, and be properly incorporated and registered within their state of operation (IRS, 2019b). Tax exemption status for non-profits does not negate their obligation to submit social security and Medicare associated taxes, Federal income withholdings, and unemployment taxes on behalf of their employees (IRS, 2024c, June 5). For profit organizations fall into several categories which are: sole proprietorship, partnership, international business, corporation, s corporation, and limited liability company (LLC) (IRS, 2019a) although they are required to file and pay all associated taxes, depending on their profits, operational cost, number of employees, and other factors they may be entitled to tax breaks and or granted the opportunity to write off certain expenditures to lower the amount of the taxes they are responsible for (IRS, 2024b, May 30). Policy, Changes, and Disparities Health care disparities are the differences within health care amongst various populations that contribute to inequalities; they can be social, economic, and or environmental that place individuals at a disadvantage in terms of their health care (Artiga et al., 2024). Two key areas of disparity within healthcare are ethnicity/race and inaccessibility. Ethnicity and racial disparities are defined as structures, policies, practices, and norms that assign value and determine opportunities, the basis of which being an individual’s ethnicity, cultural background, and skin tone; this type of disparity can either work in your favor or against you, and in many cases result in people of color having a higher prevalence of illness and disease and becoming at an increased risk of experiencing unfavorably health outcomes (Artiga et al., 2024). Inaccessibility is an issue for minority population is somewhat rooted systemic racism, however there are other

contributing factors that limit healthcare access including lacking adequate health insurance, limited financial resources, not qualifying for governmental coverage such as Medicaid due to immigration status, inability to obtain a primary care provider and reliance on urgent or emergency care entities, residing within rural areas which experience large of medical facility closures, transportation barriers, physician shortages within certain communities, communication and language barriers, and age (Artiga et al., 2024). The Affordable Care Act (ACA), enacted in 2010, addresses several of the financial and insurance coverage barriers that previously prevented individuals from obtaining healthcare, which in-turn addresses some of the racial disparities by increasing health insurance coverage for the uninsured who experienced limited income and or preexisting conditions (AMA, 2024). The ACA also eliminated the coverage dollar amount pertaining to the care of those with chronic illnesses/conditions, increased coverage for screenings and preventive services, and has made obtaining prescriptions more cost effective, especially for the elderly (Roland, 2019). Health care disparities are factored into healthcare strategic planning due to the acknowledgement of the roles external factors play in the healthcare system, such as inaccessibility (Balicer et al., 2011). A leading contributor of healthcare inaccessibility is socioeconomic barriers, which prevent individuals from seeking and obtaining quality care (Balicer et al., 2011). For healthcare entities to employ beneficial mitigation strategies and implementations to ensure individuals they can adequately meet the needs of those they serve they must first be able to reduce the disparities (Balicer et al., 2011). Successful strategic planning must incorporate strategies that acknowledge and aim to address whatever disparities they identify within their community and work to bridge those gaps for their services and resources to be sustainable, efficient, and effective.

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Organizational Impact The Shepard Center is a private non-profit, world-renowned provider of comprehensive specialized rehabilitation; Shepherd Center has been ranked among the top 10 rehabilitation hospitals in the nation (Bennewith et al., 2018). The financial background of this organization includes several funding sources to support their mission which include private and community donors, Federal and State governmental aid, various grants (Shepherd Center, 2021a), patient payments are sourced from Medicaid, Medicare, Social Security Insurance, Social Security Disability Insurance, and private insurance as well as The Georgia Indigent Care Trust Fund (Shepherd Center, 2021a). This organization and truly patient centered and the care they provide surpasses that of typical hospital entities. The Shepard Center also provides educational tools to the community to mitigate preventable injuries (Bennewith et al., 2018). The intimate setting this small facility provides allows for one-on-one treatment and limitless physician access to address any questions and concerns patients or their families may have (Bennewith et al., 2018). The uniqueness of what they offer makes them profitable and their services invaluable. Over half of all hospitals in the United States are nonprofits, a majority of which serve in capacities that advance medical research, educate providers, and fill healthcare gaps (Gee et al., 2021). Traditionally, non-profits offer free or reduced care accounting for more $23.6 billion in uncompensated care equating to roughly four percent of their operating expenses (Gee et al., 2021). Although nonprofit hospitals do not make payments to shareholders, their revenue covers the necessary operating cost and the overage is reinvested into the hospital, staff income raises, or for the betterment of the community benefits (Gee et al., 2021). Non-profits describe revenue overages that exceed their expenses as “net income”, their operating margin, which refers to their

profitability, represents the costs and revenue associated with patient care, while the total margin accounts for costs and revenues pertaining to public funding, investments, and affiliated entity income (Gee et al., 2021). For-profit hospitals are more profitable than nonprofit hospitals who offer low-margin services, such as emergency and burn care (Gee et al., 2021). Nonprofit status in no way inhibits a hospital's ability to utilize their market power to increase revenue via charge rates above justified cost (Gee et al., 2021). In the U.S. nonprofits comprise approximately 5.6% of the gross domestic product (GDP) which leads policymakers to conclude that charitable giving and financial stability of nonprofits correlates with the state of the economy (Freedman, 2023). Nonprofits continuously contribute to the economy even during times of inflation, however economic uncertainty affects their profitability because of economic instability their donors and financial partners may experience which impacts their ability to give, volunteer, and advocate (Freedman, 2023). Financials, Market, and Demand Demand Theory The Shepherd Center’s fiscal year annual reports and financial records reflect the demand theory by presenting services they added to fill gaps, increases in patient intake for certain services/treatments, staffing, charitable donations campaign goals, overall number of patients aided, and differences in revenue for fiscal years 2022 and 2023. Based on identified patient needs in fiscal year 2023, Shepherd’s added a Bowel and Bladder Program for individuals who face difficulties as a result of multiple sclerosis, the Adulting Program to aid in the transition process post-discharge following their lengthy rehabilitative hospitalization to provide guidance in areas such as reestablishing a career,

financial planning, rebuilding relationships, and health literacy, as well as the SHARE Military Initiative for military veterans, service members, and first responders requiring assistance to over struggles associated with traumatic brain injuries and mental health issues (Shepherd Center, 2022). To accommodate those seeking care at Shepherd’s, two new buildings were opened to increase patient access, implemented a fourth Comprehensive Rehabilitation Unit (CRU) team, and acquired to new specialty care physicians to address the urological complexities that accompany certain spinal and neurological injuries (Shepherd Center, 2022). The Shepherd Center also launched its most financially ambitious campaign in its 48-year history to raise $350 million to go toward capital and projects to benefit patients and families by increasing inpatient capacity, converting all patient rooms to private ones, implementing smart home technology, expansion of day programs and outpatient services, and centralization of their care wings (Shepherd Center, 2022). In fiscal year 2023 the Shepherd Center saw increases from individuals with spinal cord injuries, treating 80.5% of those patients in comparison to the national average of 23.3%, treated over 78.7% of patients with brain injuries in comparison to 31.5% at other facilities, their re-hospitalization rate was 6.1% up from 4.6%, and they experienced an increase in harm patients (infection and fall injury related) of 29% versus fiscal year 2022 (Shepherd Center, 2022). Operating revenue decreased from $310,267,883 in 2022 to $297,878,243 in 2023 (Shepherd Center, 2022), however operating expenses increased from $296,055,114 in 2022 to $299,226,370 (Shepherd Center, 2021a). Market Behavior Impact Done The Shepherd Center conducts a significant amount of uncompensated care annually, in fiscal year 2023 $5,964,075 went toward caring for patients facing economic barriers and $ 17,272,044 was spent to cover underfunded government programs (Shepherd Center, 2022),

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presenting a decrease in unfunded patient spending in comparison to 2022 ($8,358,356), and an increase in underfunded programming spending in comparison to 2022 ($15,869,272) (Shepherd Center, 2021a). These financial variations are indicative of individuals’ reliance on their services, especially those that do not receive the necessary financial support. Outpatients increased in 2023, as well as the discharge rate for inpatients, which is indicative of not only their growth, but also the technological and research advancements that facilitate their treatment successes (Shepherd Center, 2022). Shepherd Center highlights in 2023 include, over 13,000 visitors, participating in 25,000 treatments/services both in and outpatient, from 68 countries, and all 50 states representing an accessibility increase of over 50% (Shepherd Center, 2022). The impact market/consumer behavior has had on this organization’s financial statements is an increased need for funding, especially for services that receive less governmental aid, and a larger facility to accommodate the growing number of patients. On their website, a periodically updated listing is provided containing areas in which they need funding for potential donors to choose from (Shepherd Center Foundation, 2024); these donations go directly toward a specific service they provide. They are currently in the process of building several additional wings to increase the size of the facility to accommodate the hundreds of medically qualified individuals they must deny services to annually (Shepherd Center, 2021a). Economic Legislative Changes Done Legislative Changes Legislative changes I have researched that likely have or will impact the Shepard Center include The Universal Charitable Deduction, which provides taxpayers with charitable deductions, which was once capped at $300 for single tax filers and joint filers, but was

temporarily expanded allowing single filers to deduct $600 and joint filers to deduct $1200 during COVID, The Nonprofit Sector Strength and Partnership Act of 2022 to establish an interagency council on nonprofit sector partnership, develop an advisory board to oversee nonprofits, and conduct reviews to determine the effects of legislation and regulation on charitable donating, and the Accelerate Charitable Efforts (ACE) Act to encourage fund distribution of funds amongst private foundations and nonprofit organizations faster (Ehrenfried, 2022). These pieces of legislation could have potentially deterred donors, due to excessive oversight but could potentially result in more funding. The Shepherd Center became more daring with their funding campaigns and increased their goals for each fundraising event hosted during fiscal year 2023 raising $82,593,692 in donations from corporations, legacy gifts, individuals, patients and their families, as well as board members; Shepherd Center employees raised $248,885 via an employee giving campaign with over 75% employee participation (Shepherd Center, 2022). The continuation of donations despite oversight initiatives and reduced tax incentives shows how many individuals support and believe in the mission of the Shepherd Center. Policy Changes and Impact Done The recent change in legislation could potentially pose positive and negative effects on the Shepard Center. The positive impact could be increased funding from governmental donors which would aid their facility expansion process, continue to offer their services free of charge, avoid staffing layoffs, and increase the number of individuals they intake annually. The negative impacts could result in public donors becoming reluctant to donate due to the small tax incentive it provides them, possibly having to cut staff or services if they find themselves lacking

operational funds, and lowering the number of individuals they provide their services to. Charitable donations have continued and increased beyond the expectations of the Shepherd Center, however a deficit of $17,272,044 was presented in the financial data pertaining to governmental funding, which the organization covered (Shepherd Center, 2022). Statement Impact Done Financial statements are utilized to show the effectiveness and value of an organization, present areas of financial need, and provide proof that funding is being utilized and allocated appropriately. Because the needs of the population constantly change, along with legislation, ability of individuals to donate due to the economic climate, the Shepard Centers financial statements will change accordingly. If the legislation provides too much oversight on donors and donations, individuals may reduce or decline to give, or if donors do not feel there are enough incentives to donate this could result in funding gaps necessary for them to optimally operate. Based on the financial data from the Shepard Center, these legislative implementations did not have a significant negative impact on contributions which made up 18.4% of the total revenue for 2023, versus 17.4% in 2022 (Glassford et al., 2024). Overall, 2023 revenue for the Shepard Center was $320,386,335, assets were $760,249,335, liabilities totaled $88,225,837, and salary/wages expenditures were $116,108,090; all areas reflected increases from 2022 except for liabilities, which decreased from 2022 in which they were listed as $92,951,390 (Glassford et al., 2024). Potential Disparities Healthcare disparities affect accessibility within certain populations whether it be due to socioeconomic, structural, or environmental factors. The legislation being created could

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potentially widen the health disparity amongst the populations the Shepard Center services, which is predominately those who cannot afford the services they provide at other facilities, have health insurance that may not offer adequate coverage for the services they seek, or do not have local facilities specific rehabilitative services; The Shepard Center provides alternative funding to those who incur these issues and the intake process requires disclosures to assess financial and coverage needs. Potential disparities pose an issue if they were forced to discontinue or modify services due to legislation implementation due to the number of those experiencing socioeconomic barriers who depend on them to access the multitude of life changing services they provide. Addressing these potential disparities to mitigate any negative impact they may have on the organization, the recommendation would be to explore additional indigent funding sources, work closer with insurers to find ways to expand service coverage, continue their aggressive charitable campaigns which have thus far been succeeding in gaining the necessary financing to ensure their patients care remains optimal and needed resources are incorporated, and advocate for Georgia to expand the Affordable Care Act (ACA) to aid in the development of policies to eliminate healthcare disparities.

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Johnson, M., Cade, E., Leslie, D., Bennewith, A., Morrison, S., Shepard, J., Shepard, J., Yochelson, M., Johnson, S., McDowell, S., Frazier, J., Conners, S., & Bowman, B. (2018). Shepherd Center Community Health Needs Assessment & Implementation Plan. https://www.shepherd.org/files/file/FY-2020-Annual-Report.pdf Broughel, J. (2023, November 20). The paradox of profit: The difference between for-profit and non-profit organizations. Econlib. https://www.econlib.org/the-paradox-of-profit-the- difference-between-for-profit-and-non-profit-organizations/ Ehrenfried, S. (2022, July 22). Legislative roundup – key legislation before Congress impacting the nonprofit sector: Giving USA . Giving USA | A public service initiative of the Giving Institute. https://givingusa.org/legislative-roundup-key-legislation-before-congress- impacting-the-nonprofit-sector/ Frakt, A. B. (2011, March). How much do hospitals cost shift? A review of the evidence. The Milbank quarterly. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160596/ Freedman, H. (2023, November 27). Cracks in the health of U.S. nonprofits . Independent Sector. https://independentsector.org/blog/cracks-in-the-health-of-u-s-nonprofits/ Gee, E., & Waldrop, T. (2021, August 19). Policies to hold nonprofit hospitals accountable . Center for American Progress. https://www.americanprogress.org/article/policies-to- hold-nonprofit-hospitals-accountable/ Glassford, A., & Suozzo, A. (2024, July 11). Shepherd Center Inc - Nonprofit Explorer . ProPublica. https://projects.propublica.org/nonprofits/organizations/510141601

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Henderson, J.W. (2018). Health Economics and Policy (7th ed.). Cengage Learning Inc. Internal Revenue Service. (2019a). Businesses | Internal Revenue Service . Irs.gov. https://www.irs.gov/businesses Internal Revenue Service. (2019b). Exempt Organization Types | Internal Revenue Service . Irs.gov. https://www.irs.gov/charities-non-profits/exempt-organization-types Internal Revenue Service. (2019c). Exemption Requirements - 501(c)(3) Organizations | Internal Revenue Service . Irs.gov; IRS. https://www.irs.gov/charities-non-profits/charitable- organizations/exemption-requirements-501c3-organizations Internal Revenue Service. (2024a, March 29). Federal Tax Obligations of Non-Profit Corporations | Internal Revenue Service . Www.irs.gov . https://www.irs.gov/charities- non-profits/federal-tax-obligations-of-non-profit-corporations Internal Revenue Service. (2024b, May 30). Businesses | Internal Revenue Service . Www.irs.gov . https://www.irs.gov/credits-deductions/businesses Internal Revenue Service. (2024c, June 5). Exempt Organizations: What Are Employment Taxes? | Internal Revenue Service . Www.irs.gov . https://www.irs.gov/charities-non-profits/exempt-organizations-what-are-employment- taxes National Institute on Disability, Independent Living, and Rehabilitation Research. (2022). FISCAL YEAR (FY) 2022 Why Shepherd? COMPREHENSIVE CONTINUUM OF

CARE. In Shepherd Center . https://www.shepherd.org/docs/Why%20Shepherd %20Scorecard/WhyShepherd_2022-23.pdf National Safety Council. (2024, May 6). Car crashes by time of day and day of week . Injury Facts. https://injuryfacts.nsc.org/motor-vehicle/overview/crashes-by-time-of-day-and- day-of-week/ Ndugga, N., & Artiga, S. (2024, May 2). Disparities in health and health care: 5 key questions and answers. KFF. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and- health-care-5-key-question-and-answers/ Parkin, D. (2017). Principles of Health Economics including: The notions of scarcity, supply and demand, distinctions between need and demand, opportunity cost, discounting, time horizons, margins, efficiency and equity. Principles of health economics including: the notions of scarcity, supply and demand, distinctions between need and demand, opportunity cost, discounting, time horizons, margins, efficiency and equity | Health Knowledge. https://www.healthknowledge.org.uk/public-health-textbook/medical- sociology-policy-economics/4d-health-economics/principles-he Popowitz, E. (2023, November 9). What is the difference between nonprofit and for-profit hospitals?. Definitive Healthcare. https://www.definitivehc.com /blog/the-difference- between-non-profit-and-for-profit-hospitals#:~:text=As%20said%20above%2C%20for %2Dprofit,%2C%20state%2C%20or%20local%20levels .

Roland, J. (2019, August 17). The pros and cons of Obamacare. Healthline. https://www.healthline.com/health/consumer-healthcare-guide/pros-and-cons- obamacare#pros Rosenman, R., & Friesner, D. (2009, February). Do hospitals practice cream skimming?. Health services management research. https://pubmed.ncbi.nlm.nih.gov/19182097/#:~:text= ’Cream%20skimming’%20refers %20to%20choosing,means%20choosing%20less%20ill%20patients. Sacks, D., Drakes, C., & Simon, K. (2020, July 9). Same game, different names: Cream- skimming in the post-ACA individual health insurance market - Daniel W. Sacks, Coleman Drake, Jean M. Abraham, Kosali Simon, 2020. https://journals.sagepub.com/doi/full/10.1177/0046958020933765 Shepherd Center. (2021a). OUR TRUE NORTH Annual Report-Fiscal Year 2022 . https://www.shepherd.org/docs/About/Publications/Annual%20Reports/shepherd-center- annual-report-2022.pdf Shepherd Center. (2021b, December 8). Shepherd Center Provides Plans for Expansion . Shepherd Center Provides Plans for Expansion. https://news.shepherd.org/shepherd- center-provides-plans-for-expansion/ Shepherd Center. (2022). Taking Flight Annual Report -Fiscal Year 2023 . https://www.shepherd.org/docs/About/Publications/Annual%20Reports/shepherd-center- annual-report-2023.pdf

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Shepherd Center. (2023a). Family Housing | Shepherd Center . Shepherd.org. https://www.shepherd.org/admissions/family-housing Shepherd Center. (2023b). Inpatient Admissions Process | Shepherd Center . Shepherd.org. https://www.shepherd.org/admissions/become-a-patient/inpatient Shepherd Center. (2024a). About Shepherd Center | Our History, Purpose, & Information . Shepherd.org. https://www.shepherd.org/about Shepherd Center. (2024b). Shepherd Center History and Mission | About Shepherd Center . Shepherd.org. https://www.shepherd.org/about/history-and-mission Shepherd Center Foundation. (2024). Areas of Need . Shepherd Center Foundation. https://foundation.shepherd.org/areas-of-need/ Suozzo, A. (2024, July 11). Shepherd Center Inc, full filing - nonprofit Explorer . ProPublica. https://projects.propublica.org/nonprofits/organizations/510141601/20242039934930122 7/full United States of Care. (2024, March). An explanation of hospital cost shifting. https://unitedstatesofcare.org/wp-content/uploads/2024/03/An-Explanation-of-Hospital- Cost-Shifting.pdf Wagenschieber, E., & Blunck, D. (2024, March 16). Impact of reimbursement systems on Patient Care – A systematic review of Systematic Reviews - Health Economics Review. BioMed Central. https://healtheconomicsreview.biomedcentral.com/articles/10.1186/s13561-024- 00487-6

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