This thesis is historical in nature. It adopts a methodology that has recently taken the study of accounting history into the arena of the social; leaving behind tradi- tional notions of accounting as being only what accountants do. The focus of the study is on the annual reporting of activity, in terms of both its nancial and phys- ical dimensions, in the history of the British voluntary hospital movement. The study is highly contextualised. By adopting this approach it has been possible to show how accounting reports initially enabled the managers of medical institutions to reverse the focus of accountability onto those charitable individuals that were providing the funding for the hospitals. This greatly strengthened the fundrais- ing capacity of the hospital, while simultaneously de ecting attention away from the e cacy of the institution itself. Later, however, it is shown that after various abortive or only partially successful attempts, it was possible, through the medium of a uniform accounting system, to return the focus of accountability back onto the management of the hospitals. It is important to note that the success of this movement was contingent less on the quality or viability of the accounting system than the legitimacy of the organisation that published its results. Until this legit- imacy was established in the minds of the users of the accounts the e ects of the accounting was severely limited. Once it was rmly established the accounts be- came a powerful knowledge technology that enabled a substantial degree of control to be exercised over hospitals, such that a `quasi-system' of hospitals was created.

Academic Health Centers (AHCs) hold a unique place in today’s health care environment. They service their communities through a tripartite mission of education, research, and provision of complex care to disadvantaged populations. To achieve this mission, AHCs face challenges in funding and cost containment compared to non-AHCs. Additionally, the implementation of government programs like the Hospital Readmission Rate Program (HRRP) and Value Based Purchasing (VBP) have the potential to affect AHCs differently from non-AHCs. While AHC’s unique features are known and there has been research to date on HRRP and VBP, literature has yet to statistically explore the financial differences between AHCs and non-AHCs and how HRRP and VBP may have differentially affected AHCs compared to non-AHCs. The objectives of this study are to explore financial differences between AHCs and non-AHCs and the impact that HRRP and VBP has had on these two types of organizations through the use of a contingency theory framework. Contingency theory is an organizational theory that seeks to explain variations in organizational performance over time by studying internal and external environmental influences. Guided by Contingency Theory, the study used a non-randomized, quasi-experimental, retrospective study design to evaluate two hypotheses. The study sample consisted of a total of 10,157 (991 AHCs) US non-rural hospital years from 2011 through 2015. The study used operating margin and total margin as the key measures of hospital financial performance for the dependent variables. HRRP and VBP were combined into a single independent variable along with hospital type differentiating AHCs from non-AHCs. Covariates of Herfindahl-Hirschman Index, Medicaid expansion, health system affiliation, and ownership structure were used to control for other environmental influences. A repeated measure analysis of variance was employed to test the difference between the two hospital groups in isolation of HRRP, VBP, and covariates and a repeated measure analysis of variance with covariance was used to test the full model, which incorporated HRRP, VBP, and covariates. The results of the analysis support the significance of HRRP and VBP on hospital operating margin, but the results did not support a differential effect of these programs on AHCs as compared to non-AHCs. While the results did not support the two main hypotheses, it did provide valuable insight into the financial differences between AHCs and non-AHCs and the importance of VBP and HRRP on hospital financial performance. The results also provide important policy implications and thoughts on potential managerial actions given the HRRP and VBP programs.

In 2013, Medicare launched the Bundled Payments for Care Improvement (BPCI) Initiative which linked payments for multiple services for a complete episode of patient care. With this innovative reimbursement model, hospitals accepted fixed target payments for certain types of clinical diagnoses that were intended to support better care coordination and better outcomes for patients at lower cost to Medicare. This was one of many programs aimed at addressing the serious challenges facing United States healthcare, including costs that are skyrocketing to unsustainable levels and lack of coordination of care across venues. Preliminary Medicare results showed that bundled payments might lead to lower costs and higher quality of care, however, this idea comes from a relatively small sample size and limited run time of the program. This study examined one large community hospital in the southeast part of the United States participating in the BPCI Initiative. Patient level data was retrospectively analyzed using statistical techniques to determine if financial, operational and clinical outcomes improved as result of the BPCI program compared to similar patient data before the program. The results were mixed. Financial outcomes did not change significantly, and remained higher than the CMS targets. Length of stay decreased significantly, as anticipated. The 30-day readmissions was statistically unchanged. This study illuminated both challenges and strategies in implementing bundled payments to achieve positive financial, operational, and clinical outcomes.