Although Orlando is a medium-sized metro, its two main hospital systems rank in the big leagues of top-grossing nonprofit hospitals in the nation, according to a recent report.
With annual gross charges of $8 billion, Florida Hospital came in fourth out of nearly 3,000 nonprofit hospitals, according to Becker's Hospital Review, which tracks the financial data of hospitals and health systems for national comparisons. On the same list, which was based on 2010 data, Orlando Regional Medical Center ranked 11th, with annual gross charges of $5.7 billion.
"Having one top-grossing hospital in a market the size of Orlando is unusual; having two is unheard of," said Gerard Anderson, professor of health economics at Johns Hopkins Bloomberg School of Public Health.
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For many Orlando residents, having two thriving hospital systems that provide tens of thousands of jobs is a point of pride. Others see their impressive revenues as a potential boon for the area's uninsured.
That's because as nonprofits, the hospital systems are tasked with plowing their profits back into the community, often by providing free care for the poor and uninsured. In exchange, they pay no taxes. Their for-profit peers, on the other hand, divvy their earnings among shareholders and pay taxes, Anderson said.
But it's hard for community members to know whether hospitals are giving enough back.
"Since they don't pay taxes, their return to the community should be significant," said Bruce Ruben, president of the Florida Hospital Association, a trade group representing the state's hospitals.
Some believe strongly that it is not.
"Nonprofits hospitals are nothing more than big businesses that happen to sell health services, and they need to be treated like businesses," said John Colombo, law professor at the University of Illinois at Urbana-Champaign and an expert in nonprofit tax exemptions.
"We need to get over the fact that at the turn of the century nonprofit hospitals were the equivalent of poorhouses. They were where the poor went to die," Colombo said. "They were run by volunteers and religious orders, and that's how we got used to the fact that they all should be tax-exempt.
"But that's not the world we live in anymore. The nuns are gone," he said. "Many nonprofits are extremely profitable. We need to get rid of the notion that they ought to be tax-exempt."
The chief financial officers for Florida Hospital and Orlando Health see things differently.
"If you compared what we don't pay in taxes to what we give to the community in benefit, the taxes wouldn't come up anywhere close," said Florida Hospital CFO Ed Soler.
However, Soler said he didn't know how much the hospital's taxes would be if it had to pay them.
Orlando Health would likely owe about $50 million a year in taxes, CFO Paul Goldstein said.
"We returned three times that," he said, referring to the $149 million the hospital reported as community benefit to the Internal Revenue Service.
If a nonprofit hospital doesn't give enough back to the community, its tax-exempt status can be at risk.
Since 2010, four hospitals in Illinois have had their tax-exempt status revoked or challenged for not providing enough charitable care.
Last month, the city of Pittsburgh asked a court to remove the tax-exempt status of the University of Pittsburgh Medical Center for not contributing more to the city. The suit alleges that the hospital's rate of charitable contribution did not keep pace with its revenues.
The hospital was the top-grossing nonprofit hospital on Becker's list.