In the evolving health care landscape, mergers between nonprofit health care organizations are becoming increasingly common. Mergers are often driven by a combination of economic factors, the need to improve quality and efficiency of care, and the desire to create value for patients and communities. As the first post in our nonprofit merger series, we will explore why nonprofit health care entities may consider a merger, analyze the economic pressures influencing such decisions, and discuss the structures of nonprofit transactions, including the differences between member substitutions and true mergers. Forthcoming posts in this series will examine the unique due diligence concerns, regulatory approvals, and financing arrangements involved in nonprofit health care mergers.

The Economic Drivers of Nonprofit Health Care Mergers

1. Cost Efficiency and Scale Economies

It is not unusual to find multiple nonprofit health care organizations serving the same or similar patient community in a given market or region. Although competition within a for-profit industry may be seen as beneficial for consumers, most nonprofit health care organizations are competing for the same sources of government funding and/or charitable donations for their capital needs, which can weaken or inhibit the impact of their work both individually and in the aggregate.

As a result, overlapping nonprofits may realize significant economies of scale and make a substantially greater impact by joining forces and centralizing their efforts through a merger. By combining their operations, two organizations can reduce duplicative costs in areas such as administration, technology, and supply chain management. For example, by consolidating back-office functions such as human resources, billing, and procurement, a merged entity can lower its operational expenses and redirect those savings into improving patient care and expanding services. For smaller entities in particular, the cost of implementing advanced medical technology or transitioning to new electronic health record (EHR) systems can be prohibitive. By merging, organizations may be better equipped to absorb these costs and ensure their long-term financial sustainability.

2. Increased Bargaining Power with Payers and Third Parties

Another economic factor is the increased leverage that a larger health care organization has when negotiating with insurance companies and other payors. Together, a merged organization can exercise more market power and negotiate better reimbursement rates than any of the parties could on their own. Higher reimbursement can significantly improve the financial outlook for a nonprofit health care organization, which must carefully balance its mission with its financial health. Before proceeding with a merger, the parties will often engage a third-party consultant to analyze their current payor arrangements and identify opportunities for improvement.

3. Access to Capital

Nonprofit health care organizations, unlike their for-profit counterparts, do not have access to equity markets to raise capital. Mergers can offer a solution to this challenge. By merging, two organizations can improve their creditworthiness, making it easier to obtain loans and other forms of debt financing for future expansion, facility improvements, or technology upgrades. This is particularly important as health care organizations seek to invest in value-based care models that require significant upfront investment in care coordination, population health management, and IT infrastructure. Lending arrangements for nonprofits are typically quite challenging due to concerns about maintaining tax status, use of funds, and restrictions associated with both. It is not uncommon for organizations to restructure their lending arrangements and partners during a merger process or immediately thereafter.

Improving Delivery of Care

1. Enhancing Quality of Care

One of the key motivations for a nonprofit merger is to improve quality and continuity of care. Smaller health care organizations, particularly those in rural areas, may struggle to provide specialized services or maintain high clinical practice standards due to more limited resources. A merger allows the parties to pool their resources and share best practices to build a more efficient and effective care delivery system, thereby improving patient outcomes and practitioner recruitment efforts.

Additionally, mergers can help organizations streamline care pathways. For instance, a health care system with multiple facilities may create better-integrated care models, improving coordination between primary care, specialty care, and hospital services. This enhances patient outcomes by reducing duplication of services, minimizing delays in care, and ensuring that patients receive the appropriate care in the most efficient setting.

2. Expanding Access to Care

For many nonprofit health care organizations, expanding access to care — especially for underserved populations — is a central part of their mission. Mergers can help organizations achieve this goal by expanding their geographic reach and the range of services that they can provide. For example, a small community hospital may merge with a larger regional health system to provide its patients with access to specialized services that were previously unavailable locally, such as oncology or cardiology.

Furthermore, mergers may enable organizations to better address social determinants of health, which is increasingly recognized as critical to improving population health. For example, a Federally Qualified Health Center (FQHC) with a strong primary care practice may consider merging with a nonprofit community-based behavior health clinic to create an integrated preventative care network specific to the medical and behavioral health needs of its community. The larger, more financially stable merged organization may then be able to invest additional resources in community health initiatives, such as housing support and food security programs.

3. Investing in Innovation

Health care providers, and particularly nonprofits, may find it difficult to keep up with the rapid pace of innovation in the health care sector. Merged organizations are often better positioned to invest in these innovations, particularly in areas like telemedicine, data analytics, precision medicine, and value-based care models. By combining resources and patient base data, nonprofit health care organizations can become more responsive to the health care needs of their patient community, contributing to improved clinical outcomes and, in turn, a more financially stable future.

Value Creation Beyond Economics and Care Delivery

1. Mission Alignment

Nonprofit health care organizations are mission-driven, with the goal of serving their communities and improving health outcomes. When two nonprofit organizations merge, they typically seek to align their missions and values. This alignment is essential for ensuring the new entity remains focused on its core objective — whether that is serving a particular patient population, improving community health, or promoting medical research and education.

This often creates a situation where the two parties to the proposed merger are forced to negotiate a revised set of bylaws better suited for the combined entity post-closing. Important in this negotiation is understanding the terms around board structure, committees, executive officers, and general governance post-closing. It is not uncommon to see an expanded board or some combination of the two boards along with a realignment in officer positions. This is often an area of significant negotiation during the merger process.

2. Organizational Culture and Leadership Stability

In the nonprofit health care sector, where mission and values are paramount, ensuring that the two organizations’ cultures are compatible is essential. A well-executed merger offers a unique opportunity to bring fresh perspectives into leadership while preserving and building upon the parties’ existing strengths. By integrating their boards and leadership teams, merged organizations may foster the environment for more innovative and effective strategies for fulfilling a unified mission.

Structures of Nonprofit Health Care Transactions

Nonprofit health care mergers utilize unique transaction structures, primarily because they do not have shareholders and are organized for charitable purposes. Two common structures for combining nonprofit health care organizations include a member substitution and a true merger per state law.

1. Member Substitution

In a member substitution transaction, one nonprofit organization becomes the controlling member of another nonprofit without the two organizations dissolving or fully integrating into a single entity. The sole member (usually the parent organization) gains the authority to appoint the board members of the other organization and effectively controls its governance and operations. Note that a member substitution may not be viable in some states where nonprofit entities are not required or permitted to have members.

• Benefits: Member substitution is often viewed as a less disruptive approach compared to a true merger. With a member substitution, the controlled entity retains its legal identity, which can help preserve relationships with donors, the community, and key stakeholders. This structure can also be advantageous for organizations wanting to maintain some degree of autonomy, particularly if they have a strong local presence or identity. Also important is that this structure still maintains separation of liabilities between each entity, i.e., liabilities of the nonprofit relinquishing control do not become the liabilities of the controlling member. A merger between a large health system and a smaller, local hospital may elect this structure in order to minimize disruption to the controlled entity’s local operations.
• Challenges: The drawback of a member substitution is that it may not achieve the full benefits of integration, such as cost savings or streamlined operations. There may also be governance challenges if the controlled entity’s leadership or board resists the level of oversight imposed by the parent organization. Administratively, a member substitution can also be challenging because of the multiple levels of board governance.

2. True Merger

In a true merger, two or more nonprofit health care organizations combine into a single legal entity. The merged organization typically has a unified governance structure, leadership team, and operational model. This type of merger represents full integration and can provide the most significant opportunities for cost savings, operational efficiencies, and strategic growth.

• Benefits: A true merger allows for complete consolidation of assets, liabilities, and operations. The merged organization can realize the maximum potential for economies of scale, enhanced bargaining power, and operational integration. Additionally, a true merger simplifies governance by creating a single board of directors and a unified executive leadership team.
• Challenges: A true merger is more complex and may require regulatory approvals, including from the state attorney general or other regulatory bodies overseeing nonprofit or health care entities. The process can be time-consuming and may involve significant costs associated with legal, financial, and operational integration. A true merger also means that the surviving entity inherits the liabilities of the merged entity, which can result in unforeseen liability and risks for the surviving entity.

Conclusion

Mergers among nonprofit health care organizations are driven by a combination of economic pressures, the need to improve care delivery, and the desire to create long-term value for patients and communities. Whether through a member substitution or a true merger, these transactions can help organizations achieve financial stability, enhance quality of care, and expand access to services. However, nonprofit mergers require careful planning, particularly around governance, cultural integration, and mission alignment, to ensure that the merged organization remains focused on its charitable objectives and continues to serve its community effectively.

For nonprofit health care organizations considering a merger, it is essential to weigh both the financial and operational benefits, as well as the impact on the mission, before moving forward. With the right strategic approach, a merger can both strengthen the financial position of the parties and enhance their ability to serve their patients and communities.