Baylor Scott & White Health is the largest not-for-profit hospital system in Texas, and it’s growing like it.

In the past two years, annual revenue increased by $1 billion and operating income more than doubled to $725 million in 2019. Not bad for a nonprofit, especially when its traditional business is in decline.

From 2017 to 2019, Baylor’s annual hospital admissions fell by 13,000, a decline of 5.5%. And the average number of hospital patients fell by 200 a day.

“Hospital inpatient stays are no longer the best barometer of health care activity,” said CEO Jim Hinton. “We’re going to need to rethink the measurements of success.”

Start with this: Last year, Baylor had 12 million visits and encounters in its outpatient business -- 3.5 million more than in 2015. That includes an increase of 50,000 outpatient surgeries a year.

In 2019, 63.1% of Baylor’s patient revenue came from the outpatient side, almost 4 percentage points higher than four years earlier. And those trends are intentional.

“We have several partnerships with companies in the outpatient world,” Hinton said, citing United Surgical Partners International and Touchstone Medical Imaging. “We’ve led this market in partnering with others to more dramatically increase business into these ambulatory settings.”

The push for value-based health care is all about getting people to the right treatment at the right time, and avoiding costly hospital trips. Baylor has reduced the average hospital stay to 4.4 days, a decline of almost 10% in four years.

Officials also focused on cutting hospital readmissions, a major cost driver. When patients check out, Baylor hospitals schedule follow-up appointments with their primary care doctors, a proven strategy for improving outcomes.

Baylor also operates a fast-growing accountable care organization with a vast network of doctors, nurses and facilities. The ACO, which is projected to cover over 800,000 lives this year, includes care managers to help patients navigate the system.

The ACO has helped bend the cost curve in Baylor’s employee health plan, keeping monthly premiums far below the growth in prices nationwide. That record has helped attract customers with employer-sponsored insurance, Medicare and Medicaid.

If the ACO helps patients stay healthy -- by encouraging more primary care and ensuring that patients keep up with their medication, for example -- the strategy is working as envisioned, said Peter McCanna, president of the Baylor health system.

“These efforts keep people out of the hospital, and they use more outpatient services,” McCanna said. “That reduces out-of-pocket costs and reduces the cost of care in the health system.”

All that sounds great, said Marianne Fazen, executive director of the Dallas-Fort Worth Business Group on Health. But she’s skeptical about the beneficiaries of such progress.

“When hospitals get all this extra money, do they share it and lower prices?” Fazen said. “Or do they open new medical centers up north? They’re all expanding because so many high-paid employers and employees live up there.”

The D-FW business group includes over 165 companies with about 238,000 workers. They work together on strategies to lower health costs.

Fazen said many employers have learned to live with steady increases in health prices, in part because health insurance and legal compliance have become so complicated. She said human resources departments have been getting smaller and many companies are reluctant to dive into something new, such as ACO models.

“They just don’t have the bandwidth to cover all these different battlefronts,” Fazen said.

In the past two years, Baylor’s operating margins have increased from 3.2% to 7.2%. Those earnings are important to making investments in the system, including $350 million for electronic records, McCanna said.

That project, expected to be completed by late summer, will make patient information available on one record throughout the Baylor system. The records will become “a building block to having much better coordination of care,” he said.

“We really believe that better quality leads to more affordability and lower costs,” McCanna said.

Baylor is not exactly a low-cost leader, at least according to a Rand Corp. study of hospital prices in 25 states. Rand found that private health plans were ponying up much more than the government -- paying 241% of Medicare rates in 2017 in the states in the study.

Relative prices in Texas were slightly higher, and the Baylor system was higher still, charging 264% of Medicare rates, Rand reported.

For many years, prices paid by the government haven’t covered the actual costs of providing care, McCanna said, so cost-shifting has been a feature of the U.S. health system. Those with employer coverage have generally absorbed the financial hit. And in Texas, such problems are exacerbated because 5 million residents don’t have insurance, far more than in any state.

The shift toward more outpatient service is a major step in the right direction, but provider markups were even higher, Rand said. Baylor charged 330% more than Medicare rates for outpatient work, about one-third more than its inpatient premium.

Baylor said it’s been focusing on cutting expenses, but customers may not see that in their bills.

“We’ve taken a lot of costs out of the system," said CEO Hinton, "and then reinvested in digital capabilities and other venues.”