State laws and nonprofit hospital community benefit spending. Young GJ, Chou CH, Alexander J, Lee SY, Raver E. Provision of community benefits by tax-exempt U.S. hospitals. These articles responded to the need for researchers and practitioners to understand the new expectations emerging from the IRS revisions and the ACA. Nonprofit Hospitals and Community Benefit - National Health Law Program The so-called "non-profit" hospitals CEOs are making $10 million, $18 million and even $21.6 million per year. Studying changes in CHNAs and CHIPs over time will be more possible now that most hospitals have completed three full cycles. Accessibility How to Partner with Hospitals for Community-Based Services Studies on this topic often employed case-study methodology to describe hospital-community engagement, often in rural settings. Each section of the results begins with the research question that animates the studies in that section (see Table 1). These included some early peer-reviewed overviews (44, 45), with others provided by organizations with interest in educating the public on community benefit, such as from The Hilltop Institute (2, 5) or Catholic Health Association (46, 47). Powell RE, Doty AMB, Rising KL, Karp DN, Baehr A, Carr BG. One group of studies focused primarily on the effect the process had on collaborating organizations. What Makes A Non-Profit Hospital? | The Incidental Economist Bakken and Kindig did projections to show that community health spending would increase 3-fold if hospitals were required to spend a certain percentage of community benefit dollars on community health improvement (10% minimum, which would increase as hospital profitability increased) (105). Community health needs assessment in Wake County, North Carolina: partnership of public health, hospitals, academia, and other stakeholders. Several recent studies have examined whether the ACA influenced the amount or patterns of spending on community benefit. First, articles were collected using the method previously suggested by community benefit researchers, using the OvidSP MEDLINE search terms (14). Exempt Organization Update December 18, 20159. Second, the expansion of Medicaid and the inclusion of guaranteed issue creates an environment similar to that following the original passage of Medicare and Medicaid, wherein many question whether tax-exempt status is justified given the possible decrease in charity care (610). EIN: 75-2638469. These measures included charity care as reported in financial statements (adjusted with the cost to charge ratio), the Medi-Cal inpatient load, and measures of community orientation and provision of community health services constructed from data in the annual AHA survey. They identified several reasons including lack of resources, risk aversion, and stigma. The first focuses on those studies that analyze how much is spent and whether that spending changes over time; the second summarizes associations with or influences of spending. Nonprofit Hospital Community Benefit in the U.S.: A Scoping Review From But this kind of shift does not just happen, which is why other articles, often appearing in gray literature, offer suggestions as to how an organization can best manage community benefit's relationship with population health. In 2020, there were around 5,139 community hospitals in the United States. 2 What do nonprofit hospitals reward? Some articles were excluded if they were published during the accepted date range but exclusively used data that preceded the IRS revision and the ACA. This scoping review identified a significant amount of literature published on community benefit since the IRS revisions and ACA regulations, in all areas of scholarship identified by a 2009 working group (19). Caffrey A, Pointer C, Steward D, Vohra S. The role of community health needs assessments in medicalizing poverty. Viewing telehealth through the lens of a community benefit mission, Nonprofit hospitals' process for community health improvement: a qualitative study of leading practices and missing links, Are you making an impact? This scoping review found leveraging community benefit for population health to be the most frequent policy recommendation. The most common reason for exclusion was the article addressed hospitals' community health or population health work, but did not connect that work to community benefit. But Magill and Prybil suggested that the need for board oversight goes beyond legal compliance toward an ethical imperative, indicating that board engagement, deliberative communication, and performance measurement are essential markers of meeting the ethical demands of community benefit (20). If health care organizations are interested in broadening the community benefit conversation beyond spending, as I suspect many are, it would behoove them to help researchers more easily secure the data necessary to answer questions associated with these other areas of community benefit. Hospitals' Obligations to Address Social Determinants of Health For example, a recent study analyzed data from 1,405 non-profit hospitals to identify an association between increased community-directed spending and lower preventable readmission rates (31). The most prominent aspect of the Internal Revenue Service (IRS) ruling was that hospitals would be tax-exempt if they provided charity care or uncompensated care within their financial ability to do so (1). The Patient Protection and Affordable Care Act of 2010 specified tax exemption requirements for nonprofit hospitals78% of US hospitals in 2014. The . The progress of US hospitals in addressing community health needs, Getting more for your money: designing community needs assessments to build collaboration and capacity in hospital system community benefit work, Building community while complying with the affordable care act in the lehigh valley of Pennsylvania. Shaping organizational action and public policy would benefit from additional research in these and other areas. found state laws increased total community benefit spending, but that rural hospitals responded to state community benefit laws to a lesser degree than did urban hospitals (90). As a scoping review, this study identifies the major topic areas but does not claim to identify all the articles within a given topic area as a systematic review would. Leider JP, Tung GJ, Lindrooth RC, Johnson EK, Hardy R, Castrucci BC. : Non-profit hospitals must complete a Community Health Needs Assessment and a Community Benefit Report. Many have suggested that the ACA would lead to new opportunities related to community benefit spending, namely a shift away from uncompensated care toward community health investment. Pennel et al. The Democracy Collaborative (100), Catholic Health Association (101), Community Catalyst (102), and the then-Institute of Medicine (103) are just some of the organizations to note community benefit's potential in advancing population health. Burke JG, Truong S, Albert S, Steenrod J, Gibert C, Folb B, et al.. What can be learned from the types of community benefit programs that hospitals already have in place? The Hospital Community Benefit Program is a central resource created specifically for state and local policy makers who seek to ensure that tax-exempt hospital community benefit activities are responsive to pressing community health needs. Community hospitals use a local approach focused on patient-centered care. They found little regional coordination between organizations and the implementation strategies generally overlooked behavioral health and social factors, which often arose at top needs (67). Crossley suggested that better alignment with community health could arise with more transparent and accountable guidance related to CHNAs (110), with Gruber and colleagues going even further to suggest a standardized CHNA format would increase accountability for health outcomes (42). Results: Literature appeared around several topic areas: governance; CHNA and CHIP process, content, and impact; community programs and their evaluation; spending patterns and spending influences; population health; and policy recommendations. Madera Community Hospital closed its doors in . What challenges do nonprofit hospitals face in taking on community health needs assessments? One frequent question is whether non-profit hospitals actually provide more community assistance than for-profit hospitals (82). How much money do non-profit hospitals spend on community benefit?. Community Benefit: Moving Forward With Evidence-Based Policy and Practice. Establishing a baseline: community benefit spending by not-for-profit hospitals prior to implementation of the affordable care act. The first of these returns were filed in 2009. We must also consider that any changes, either in spending or other elements that rely on organizational support, may in part be a result of organizations developing better procedures for recording spending or communicating activity. Song PH, Lee SY, Alexander JA, Seiber EE. What do we know from studying the content of CHNAs and CHIPs?. The impact of the individual mandate and Internal Revenue Service Form 990 Schedule H on community benefits from nonprofit hospitals, Changes in teaching hospitals' community benefit spending after implementation of the affordable care act, The role of non-operating income in community benefit provision by not-for-profit hospitals, Community health needs assessment: potential for population health improvement. Ainsworth, Diaz, and Schmidtlein found that a four hospital system in northern California approached the CHNA process with broader goals of collaboration in mind and that the effort had several positive effects, including regular meetings after the CHNA process and increased collaboration with other community organizations (69). Alfano-Sobsey et al. Longitudinal studies on needs assessments and spending patterns would help inform whether organizations have changed and improved operations over time. showed that community participation identified needs that hospital leadership had not identified and that strategies were modified based on the insights provided by community members (72). In 1956, the United States formalized the tax-exempt status for non-profit hospitals. engagement in the care continuum. The second and third stages are detailed in this section. Olden and Hoffman conducted a literature review on hospitals' health promotion services and identified 25 articles, all published before the date range of this scoping review. Community benefit and population health management. These conclusions align with studies that asked similar questions before the new regulations (86, 87). It is also possible that studies in the coming years will consider whether there are meaningful improvements to community health indicators because of community benefit efforts, either from direct investment or from community benefit helping create community ecosystems that are more attuned to community health. This may still be in the offing, or it could be that most of uncompensated care for the uninsured simply shifted to shortfall from Medicaid and other means-tested programs. According to a 2006 CBO report, for-profits constitute just 6% of the hospitals in the Midwest and US nurse, child abducted in Haiti, non-profit organization says Therefore, it is difficult to disentangle exactly which evidence is related to each reform. Elevance, the for-profit insurer previously known as Anthem, had plans with denial rates that varied from 6 to 34 percent, while UnitedHealthcare had plans that had rates ranging from 7 to 27 percent. Second, a PubMed search using keywords frequently found in community benefit literature. Differences: Academic vs. Community Medical Centers | GW University Spending on community benefit constitutes the plurality of literature. The variation of total community benefit spending among hospitals was also quite large, ranging from 1.1% of operating expenses for the lowest decile to 20.1% for the highest decile (15). Finally, the ACA's promotion of population health, primarily through new payment mechanisms, creates a possibility of expanding the notion of community benefit to include social determinants of health. Hospital Community Benefits | NCHH Community Health Network Foundation As part of the Health Anchor Network, over 45 hospitals and health systems have committed to an investment of $700 million to address SDOH. studied a four-hospital process in Lehigh Valley, PA and found that strategies such as identifying ambassadors from vulnerable communities and encouraging long-term memoranda of agreement were important for success (57). In it, Young and colleagues found that on average hospitals spent 7.5% of their operating expenses on community benefit, with 0.4% allocated to community health improvement. Nevertheless, nongovernmental nonprofit hospitals retain remnants of their historical missiona "charitable purpose." 3 In 2019, the American Hospital Association reported that 56% of community hospitals in the United States are organized as nongovernment nonprofit organizations, and, government hospitals included, nearly 80% of community . The https:// ensures that you are connecting to the Before National Library of Medicine What is the role of hospital leadership related to community benefit?. Bethesda, MD 20894, Web Policies Non-profit hospitals and community benefit data. Saint Louis University, St. Louis, MO, United States, Edited by: Tony Sinay, California State University, Long Beach, United States, Reviewed by: Mary Helen McSweeney-Feld, Towson University, United States; Mustafa Z. Younis, Jackson State University, United States; William Edson Aaronson, Temple University, United States, This article was submitted to Public Health Policy, a section of the journal Frontiers in Public Health. Most studies in these areas use CHNAs, CHIPs, and the American Hospital Association's annual survey from 2013 or earlier. Lightfoot et al. A literature review by Burke et al. evaluating the population health impact of community benefit programs, Comparing the value of nonprofit hospitals' tax exemption to their community benefits, What should we expect? The two reformsthe 2008 IRS ruling and the ACAare distinct but related. Developing data to support effective coordination of nonprofit hospital community benefit investments, Non-profit hospital community benefit spending based on local sociodemographics, Cleveland Clinic Reports a 40% Drop in Charity Care After Medicaid Expansion. What do we know about the programs hospitals support related to community benefit?. Third, a SCOPUS search of the most frequently cited articles in this topic area. Skinner et al. Therefore, this review may underrepresent the literature, particularly related to these topic areas. Community Hospital Corporation - Nonprofit Explorer - ProPublica . The impact of community input in community health needs assessments, Hospitals' health promotion services in their communities: findings from a literature review, The hospital community benefit program: implications for food and nutrition professionals. Hospital community benefit programs: increasing benefits to communities, Tax-exempt hospitals and community benefit: new directions in policy and practice. To judge merit of tax exemption, the amount of community benefit spending is often compared to the value of tax exemption, which a national analysis puts at $24.6 billion for the year 2011 (8). With intention and humility, nonprofit hospitals can serve the dual purpose their names and statuses evokeas providers of high-quality clinical care and as charitable institutions that seek to. After sorting into an initial set of topic areas, the articles were further sorted into subtopics. The most prominent aspect of the Internal Revenue Service (IRS) ruling was that hospitals would be tax-exempt if they provided charity care or uncompensated care within their financial ability to do so ().Less than a decade later, with the passage of Medicare and Medicaid in 1965, there was . 2,900 are non-governmental not-for profit hospitals. From the early years, we know that collaboration was quite uneven and that social determinants of health were not a central focus of community benefit efforts. The author would like to thank Allyssa Stevens for her assistance with this project. Nonprofit hospitals' spending on charity care decreased from $6.65 million in 2012 to $6.36 million in 2019, whereas for-profit hospitals increased their charity care spending from $2.29 million . Charity Care and Community Benefit in Non-Profit Hospitals: Definition Pennel et al. HHS Vulnerability Disclosure, Help Most of the existing studies use data from 2012 to 2013, when most hospitals completed their first required CHNA and CHIP. In general, internal operations related to community benefit largely remain a black box. If we do no know about these areas, the information rarely extends beyond a case study. For example, we know that boards are approving CHNAs and CHIPs, but we do not know how engaged governance structures are beyond the approval process. using 20092011 data, showed that hospitals often respond to increased regulation by favoring spending on patient care over community health improvement (39). Two empirical articles illustrate early skepticism on community benefit and population health. Does nonprofit hospital community benefit vary by state? Akintobi et al. However, the authors' findings that hospital size and collaborative networks were positively associated with more community programs and that state community benefit laws had no association with programs continue to be relevant. Mercy has more than 40 acute care and specialty hospitals. The results on state influence are mixed. Additionally, a qualitative study of 21 hospitals in the Appalachian region of Ohio found that hospitals have been formalizing their CHNA processes, cultivating local partnerships, and developing an evidence base for their work (26). Through three CHNAs in West Virginia, Bias et al. Per the American Hospital Association (AHA), 18% of U.S. hospitals are private, for-profit hospitals; 23% are . One major area of change is the requirement that all not-for-profit hospitals conduct a community . We also know that spending as a percentage of operating expenses has remained relatively steady over the early years following new regulations and that there are very few factors, either organizational, or community, that are associated with amount or distribution of spending. Those in Medicaid expansion states increased spending on Medicaid shortfall and subsidized health services more quickly than non-expansion states. About Community Healthcare System in Indiana | Community Healthcare System Articles were then selected based on their relevance to the research question. First, an OvidSP MEDLINE search using terms suggested previously by community benefit researchers. The industry remains divided on the value of nonprofit . Community health needs assessment: a pathway to the future and a vision for leaders. Although many of the articles in this topic area could be included either with evaluating impact or with policy recommendations, the large number of articles specifically relating to population health warranted its own section. Formal evaluation of community benefit programs received relatively little attention in the literature. Pennel et al. Evolving Roles of Health Care Organizations in Community Development They tend to have strong patient loyalty. In 1956, the United States formalized the tax-exempt status for non-profit hospitals. Overall, there is less scholarship on the types of community programs associated with community benefit than one might expect. Sara Rosenbaum suggested that the definition of community benefit be expanded to include community building activities (34, 104) and that the IRS be more directive in hospitals reallocating resources for community health improvement (104). The 2008 ruling had a fairly narrow focus on stricter reporting guidelines, but the reporting itself could have changed hospitals' behaviors. This raises a question of whether there may be trade-offs between spending on charity care and other spending such as community health improvement. Most people in places where there is a non-profit hospital are likely interested in one question related to community benefit. At the time of this review, there were no studies that took account of the 2019 CHNA cycle. In 2017, our Community Benefit contribution totaled $906.5 million." And we know that collaboration occurs during the needs assessment process and that the depth of collaboration is highly variable, but it is not clear how regulations could be amended to make meaningful collaboration during needs assessment and other stages of the community benefit process more likely. At a minimum, this includes, persons with special knowledge of or expertise in public health; federal, tribal, regional, State, or local health or other departments; leaders, representatives, or members of the medically underserved, low-income, and minority populations, and populations with chronic disease needs (53). Rosenbaum S, Byrnes M, Rothenberg S, Gunsalus R. Improving Community Health through Hospital Community Benefit Spending: Charting a Path to Reform. provided baseline data from the first CHNA cycle in 2013 and reported that 53% of LHDs collaborated with hospitals on needs assessments, with likelihood increasing in areas of large populations (63). Please allow extra travel time in that area for appointments. States and localities have begun comparing the level of charity care and community benefit that non- profit hospitals provide to the level of tax benefits they receive. Pennel CL, McLeroy KR, Burdine JN, Matarrita-Cascante D, Wang J. Processes and outcomes of a community-based participatory research-driven health needs assessment: a tool for moving health disparity reporting to evidence-based action. The remainder are state and local government hospitals. government site. In earlier work using Medicare cost reports from 2018, we found that for-profit hospitals in aggregate provided 65% more charity care than nonprofit ones per every $100 in total expenses. In 2011, the IRS issued a bulletin stating, a CHNA must take into account input from persons who represent the broad interests of the community served by the hospital facility (53). BEAUFORT COUNTY, Sc. California is urging residents to conserve air conditioning usage and set thermostats to 78 degrees Fahrenheit to prevent potential blackouts. With this ruling, the IRS established a broader notion of charity, wherein the promotion of health is considered to be a charitable purpose and where acceptable activities went beyond charity care as long as the activities were deemed beneficial to the community as a whole (3). The new expectations related to CHNAs and CHIPs meant most hospitals had a new skill to learn and researchers had a new process to study. a qualitative study from appalachian ohio, The journey to meet emerging community benefit requirements in a rural hospital: a case study.

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