Di­ag­nos­ing a com­mu­nity’s health needs

Not-for-profit hos­pi­tals tar­get health im­prove­ment ef­forts un­der re­form law

Modern Healthcare - - NEWS - By Steven Ross John­son

When 193-bed Ad­vo­cate Trin­ity Hospi­tal be­gan five years ago to as­sess the health needs of res­i­dents in its ser­vice area on Chicago’s South Side, it found the rate of stroke was among the high­est in Illi­nois. Deaths from heart dis­ease and cancer made up half of the more than 2,700 deaths that oc­curred in the hospi­tal’s ser­vice area in 2011.

“We mapped out a plan of what those (health) gaps were,” said Michelle Gaskill, pres­i­dent of Trin­ity. “Then we started iden­ti­fy­ing in­vest­ments we were go­ing to make over a pe­riod of time to start fill­ing those gaps.”

Over the next few years, Trin­ity, part of 11-hospi­tal Ad­vo­cate Health Care, de­vel­oped a pri­mary stroke cen­ter, which won the hospi­tal a Gold Seal of Ap­proval from the Joint Com­mis­sion in 2010. With­out that des­ig­na­tion, “Pa­tients who were hav­ing an ac­tive stroke would have had to leave this ZIP code to travel to the clos­est pri­mary stroke cen­ter,” Gaskill said.

Other ini­tia­tives in­cluded adding a sec­ond heart catheter­i­za­tion lab and new equip­ment for the ra­di­ol­ogy depart­ment. Gaskill said those in­vest­ments grew out of the find­ings of the hospi­tal’s com­mu­nity needs as­sess­ment. The to­tal cost for this new in­fra­struc­ture was nearly $80 mil­lion over five years, she said.

All not-for-profit hos­pi­tals are now re­quired by the Pa­tient Pro­tec­tion and Af­ford­able Care Act to con­duct and pub­lish sim­i­lar com­mu­nity needs as­sess­ments once ev­ery three years. They also must draft a strate­gic plan on how they will ad­dress iden­ti­fied needs. Un­der the law, hos­pi­tals face a $50,000 penalty per year and the po­ten­tial loss of their federal tax-ex­empt sta­tus for fail­ing to com­plete the as­sess­ments. The first as­sess­ment was due no later than the first tax year af­ter March 23, 2012, to be sub­mit­ted as a part of the IRS Form 990 re­port.

In April 2013, the IRS is­sued pro­posed guide­lines to pro­vide greater clar­ity on the re­quire­ments for needs as­sess­ments. Un­der the pro­posed rule, for in­stance, hos­pi­tals can­not de­fine their ser­vice ar­eas to ex­clude un­der­served, low-in­come and mi­nor­ity groups. That rule has not yet been fi­nal­ized.

The re­quire­ments grow out of crit­i­cism that not-for-profit hos­pi­tals have not pro­vided enough char­i­ta­ble ben­e­fits to their com­mu­ni­ties to jus­tify their federal and state tax­ex­empt sta­tus. Ques­tions over com­mu­nity ben­e­fits have grown as not-for-prof­its have con­sol­i­dated into larger sys­tems with bil­lions in an­nual rev­enue that act like big businesses. No federal rules gov­ern the amount of com­mu­nity ben­e­fit hos­pi­tals must pro­vide to keep their tax-ex­empt sta­tus, which was es­ti­mated to carry a value of $13 bil­lion an­nu­ally for all not-for-profit hos­pi­tals in 2008.

In 2007, the IRS re­designed its Form 990 for not-for-profit or­ga­ni­za­tions to in­clude Sched­ule H, on which tax­ex­empt hos­pi­tals must re­port the to­tal amount of char­ity care and com­mu­nity ben­e­fits they pro­vide. Only five states have set a min­i­mum amount of com­mu­nity ben­e­fit for re­tain­ing state tax-ex­empt sta­tus. Con­tro­versy over the hospi­tal tax ex­emp­tion has erupted in var­i­ous com­mu­ni­ties across the coun­try. Last year, the city of Pitts­burgh sued the UPMC sys­tem, claim­ing the sys­tem should lose its pay­roll and property tax-ex­empt sta­tus be­cause it al­legedly spends about 2% of its net pa­tient rev­enue on char­ity and dis­counted care.

An ar­ti­cle in the New Eng­land Jour­nal of Medicine last year re­ported that among more than 1,800 not-for­profit hos­pi­tals stud­ied, providers al­lo­cated an over­all aver­age of 7.5% of their op­er­at­ing ex­penses to­ward com­mu­nity ben­e­fit ser­vices and pro­grams, with the share rang­ing from as much as 20% to as low as 1.1%.

“The cur­rent stan­dards and ap­proach to tax ex­emp­tion for hos­pi­tals is rais­ing con­cerns about a lack of ac­count­abil­ity for hos­pi­tals,” said Gary Young, a pro­fes­sor and di­rec­tor of the Cen­ter for Health Pol­icy and Health­care Re­search at North­east­ern Univer­sity, who au­thored the study. “It cre­ates a prob­lem in the sense that hos­pi­tals don’t re­ally know what’s ex­pected of them.”

Shift to pop­u­la­tion health ini­tia­tives

Tra­di­tion­ally, not-for-profit hos­pi­tals have al­lo­cated the bulk of their com­mu­nity ben­e­fit spend­ing on free or dis­counted char­ity care to the poor and unin­sured, or writ­ing off bad debt from un­paid pa­tient bills. Young’s study found that more than 85% of com­mu­nity ben­e­fit spend­ing went to char­ity and dis­counted care and ser­vices not fully re­im­bursed by Med­i­caid and Medi­care. Only 5.3% went to­ward com­mu­nity health im­prove­ment ini­tia­tives such as health screen­ings and health ed­u­ca­tion. Some say hospi­tal spend­ing on pop­u­la­tion health ini­tia­tives is likely to in­crease as providers face grow­ing fi­nan­cial in­cen­tives to im­prove health out­comes and re­duce costs un­der value-based pay­ment mod­els.

Ex­perts hope that the health­care re­form law’s re­quire­ment that hos­pi­tals make their com­mu­nity needs as­sess­ments “widely avail­able” to the pub­lic will pro­vide greater trans­parency so com­mu­nity stake­hold­ers and lo­cal gov­ern­ments can bet­ter hold them ac­count­able for pro­vid­ing com­mu­nity health im­prove­ment pro­grams and other ben­e­fits.

There are no data avail­able on how many of the nearly 2,900 not-for-profit U.S. hos­pi­tals have com­plied with the law’s re­quire­ment to con­duct and pub­lish com­mu­nity needs as­sess­ments and strate­gic plans, ex­perts say. So far, there are no known cases of hos­pi­tals be­ing fined for fail­ing to com­ply. Many hos­pi­tals and health sys­tems see the re­quire­ment as an im­pe­tus to shift their fo­cus from strictly pro­vid­ing acute care to a greater em­pha­sis on pub­lic and pre­ven­tive health ini­tia­tives.

“Hos­pi­tals are work­ing very well to un­der­stand the needs of their com­mu­ni­ties, and they’re work­ing with com­mu­ni­ties and their key stake­hold­ers to have an im­pact on the key health

is­sues they want to ad­dress with their part­ners,” said Stephen Martin Jr., ex­ec­u­tive di­rec­tor of the As­so­ci­a­tion for Com­mu­nity Health Im­prove­ment at the Amer­i­can Hospi­tal As­so­ci­a­tion.

Some in­de­pen­dent ex­perts agree that the law’s needs as­sess­ment re­quire­ment has fos­tered a more col­lab­o­ra­tive ap­proach be­tween hos­pi­tals and their com­mu­ni­ties. “This has gal­va­nized people to see the pos­si­bil­ity for us­ing the com­mu­nity health needs as­sess­ment process to im­prove com­mu­nity health im­prove­ment in­vest­ments,” said Sara Rosenbaum, a pro­fes­sor of health law and pol­icy at Ge­orge Wash­ing­ton Univer­sity.

The big ques­tion

But the law does not make clear whether hos­pi­tals are re­quired to make their strate­gic plan for ad­dress­ing the iden­ti­fied needs plan widely avail­able. “The ac­tual blue­print on how the hospi­tal is go­ing to spend its money is not pub­lic,” Rosenbaum said. “This is a big ques­tion.”

Like Trin­ity, Detroit-based Henry Ford Health Sys­tem was con­duct­ing needs as­sess­ments prior to the re­form law. Henry Ford lead­ers say these as­sess­ments helped them de­velop a plan for ad­dress­ing gaps in com­mu­nity health. “It helped us ad­dress some of the non­tra­di­tional ef­forts such as so­cial de­ter­mi­nants of health and be more strate­gic and de­lib­er­ate in our ap­proach,” said Dr. Kim­ber­ly­dawn Wis­dom, the sys­tem’s chief well­ness of­fi­cer.

Based on the find­ings of its lat­est as­sess­ment in 2011, Henry Ford found that com­mu­nity stake­hold­ers iden­ti­fied heart dis­ease, di­a­betes and in­fant mor­tal­ity as the three most press­ing health is­sues. The tar­get area was Detroit, whose res­i­dents ex­pe­ri­enced higher rates of all three con­di­tions com­pared with res­i­dents in other parts of Henry Ford’s ser­vice com­mu­nity in south­east­ern Michi­gan. The as­sess­ment found Detroit res­i­dents had less ac­cess to reg­u­lar health­care ser­vices com­pared with the other ar­eas. An­other find­ing was a higher preva­lence of un­healthy life­styles, which led to Detroit hav­ing one of the high­est in­fant mor­tal­ity rates in the U.S.

In re­sponse, Henry Ford be­gan a pro­gram in 2012 called Sew Up the Safety Net for Women and Chil­dren, a part­ner­ship with com­mu­nity or­ga­ni­za­tions to ad­dress fac­tors con­tribut­ing to in­fant mor­tal­ity such as pre­ma­ture birth weight and a lack of pre­na­tal care. The pro­gram trains nav­i­ga­tors who go into city neigh­bor­hoods and find at-risk women and link them with com­mu­nity re­sources. Wis­dom said the pro­gram seems to have pro­duced a re­duc­tion in in­fant mor­tal­ity.

Such ef­forts to ad­dress pop­u­la­tion health is­sues are not new for safety net sys­tems such as Henry Ford and Trin­ity. But for many other sys­tems, it’s not yet clear whether the needs as­sess­ments re­quired un­der the law will lead to greater in­vest­ments in com­mu­nity health ini­tia­tives. “There still tends to be a fairly nar­row in­ter­pre­ta­tion of how (hos­pi­tals) ful­fill their char­i­ta­ble obli­ga­tions,” said Kevin Bar­nett, se­nior in­ves­ti­ga­tor for the Oak­land, Calif.-based re­search group Pub­lic Health In­sti­tute, who par­tic­i­pated in an anal­y­sis of com­mu­nity needs as­sess­ments done by 51 hos­pi­tals in 15 re­gions. “Most of that is viewed as the pro­vi­sion of char­ity and pub­lic pay short­falls.”

In con­duct­ing needs as­sess­ments, hos­pi­tals of­ten rely on com­mu­nity part­ners such as govern­ment health de­part­ments, re­li­gious groups, lo­cal elected of­fi­cials, schools and so­cial ser­vice or­ga­ni­za­tions to pro­vide in­put and help com­pile health data. These as­sess­ments are usu­ally over­seen by a panel as­signed by the hospi­tal’s board of di­rec­tors. Bar­nett said the best as­sess­ments take a close look at smaller parts of the hospi­tal’s ser­vice area where there are par­tic­u­lar health dis­par­i­ties rather than look­ing broadly at the en­tire county or ser­vice area. A com­mon short­com­ing is the fail­ure to ob­tain in­put from an ad­e­quate range of or­ga­ni­za­tions in the com­mu­nity, he added.

En­gag­ing com­mu­nity stake­hold­ers is only one of the chal­lenges hos­pi­tals face in con­duct­ing a needs as­sess­ment or in de­vel­op­ing a strate­gic plan. Fac­tors caus­ing poor health in a com­mu­nity are re­lated to poverty, lack of qual­ity af­ford­able hous­ing, un­em­ploy­ment, poor schools and a lack of pub­lic safety. Some ob­servers say so­lu­tions to these prob­lems go far be­yond the re­sources and ca­pa­bil­i­ties of even a large hospi­tal.

“The re­al­ity (is) that hos­pi­tals can­not solve these prob­lems, many of them com­plex and long-stand­ing, on their own,” Bar­nett said. “The bet­ter as­sess­ments that we’ve seen have re­ally made a com­mit­ment to this con­cept of shared own­er­ship through­out the com­mu­nity health as­sess­ment process.”

Part­ner­ing with com­mu­nity groups doesn’t solve ev­ery prob­lem. Some hos­pi­tals, for in­stance, are work­ing with their com­mu­ni­ties to ad­dress lack of ex­er­cise and phys­i­cal ac­tiv­ity leading to obe­sity, and part of the so­lu­tion is to get people walk­ing more. But “hos­pi­tals don’t build side­walks,” the AHA’s Martin said, adding that it’s im­por­tant to have a strong gov­ern­men­tal part­ner to help ad­dress a va­ri­ety of com­mu­nity needs.

Nev­er­the­less, ex­perts say the re­quire­ment that hos­pi­tals reg­u­larly as­sess com­mu­nity needs is likely to in­crease the col­lab­o­ra­tion be­tween hos­pi­tals and com­mu­nity part­ners and lead to stronger ac­count­abil­ity for pro­vid­ing com­mu­nity ben­e­fits, said Julie Troc­chio, se­nior di­rec­tor for com­mu­nity ben­e­fit for the Catholic Health As­so­ci­a­tion.

“For those hos­pi­tals that didn’t have a re­la­tion­ship be­fore with their lo­cal or county health de­part­ments, they do now,” she said.

Henry Ford Health Sys­tem’s Sew Up the Safety Net pro­gram held a re­source fair at a Detroit church in Septem­ber as part of an ef­fort to re­duce the city’s high rate of in­fant mor­tal­ity.

Dr. Kim­ber­ly­dawn Wis­dom of Henry Ford Health Sys­tem talks to stu­dents at­tend­ing the 2013 Gen­er­a­tion With Prom­ise Youth Sum­mit, which was spon­sored by the sys­tem.

Par­tic­i­pants and com­mu­nity rep­re­sen­ta­tives at­tend a re­source fair dur­ing the Real Moms of Detroit Expo last year. The event—a col­lab­o­ra­tion be­tween Henry Ford Health Sys­tem, other area sys­tems, lo­cal pub­lic health de­part­ments, area health agencies and two uni­ver­si­ties—was or­ga­nized to ad­dress the city’s high in­fant mor­tal­ity rate.

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