The possible sale or merger of the Visiting Nurse Association of Baltimore is the latest twist in a trend by the historic nonprofit organizations to link with other health care providers.
The idea is to be part of a larger network that can handle an insurance company's need for a host of health services -- one-stop shopping.
The affiliations have taken a variety of forms; most are loose associations with hospitals that refer patients. An outright sale to a for-profit company, one of the options being considered by the Baltimore VNA, would be most unusual.
And it raises questions about whether the VNA could continue to attract the private donations it has long used to pay for care of the indigent. Under national health reform, the VNA's indigent could actually grow, since home health care for Medicare patients won't be fully reimbursed, and many elderly may not be able to afford their share.
Founded by wealthy women who took the sick poor into their homes in the height of the Victorian era, the VNA evolved into a community service organization that was supported by donations from individuals and later from United Way and other charitable organizations.
Today there are 430 independent VNAs around the country, and they deliver the lion's share of home health care: 50 percent of all such care to Medicare recipients and 80 percent of care to Medicaid patients. Only about 10 percent of the caseload is indigent today.
As health care moves out of the hospital and into the home, VNA organizations, with their widespread delivery systems, are rapidly becoming a major market force.
"They would be very attractive for acquisition," said Sherri Christian, vice president and chief executive officer of the Denver-based Visiting Nurse Associations of America.
"But they are first and foremost 501(c)3 [charitable tax-exempt] community organizations, and reflect the character of their communities," she said. "So most of the time, they would not be interested."
In one case this year, a for-profit company purchased the VNA in Union Town, Pa. Several other sales have been reported. But "this is most definitely the exception to the rule," Ms. Christian said.
VNA groups in neighboring Pennsylvania, Delaware and Washington have affiliated in other ways, generally to create economies of scale and win contracts.
The VNA serving Washington and its Maryland suburbs, for instance, affiliated with Midatlantic Health Care System in a trial run five years ago.
Midatlantic is a nonprofit health system set up by the 900-bed Greater Washington Medical Center that also includes surgical centers and the National Rehabilitation Hospital. In April, the boards of the two organizations decided to permanently affiliate, and the VNA became a wholly owned subsidiary.
In this case, however, there was no exchange of money. The Washington VNA remains in command of its own finances and continues to serve any patient. It has its own contracts and fund-raising operations, as well as joint contracts with the health system.
Linda Maurano, president of the Washington VNA, said the change has been perceived positively by United Way and other donors. "It just allowed us to meet the need of managed care companies [to deal with one party]," she said.