Tak­ing a broader view of health

With less need for char­ity care, hos­pi­tals fo­cus on com­mu­nity health im­prove­ment

Modern Healthcare - - NEWS - By Beth Kutscher

IT’S Ten­der­loin2:45 ON A dis­trict SUNNY of THURSDAYSan Francisco, AFTERNOONand com­mu­ni­tyIN THE GANG-RID­DEN vol­un­teers wear­ing lime-green and or­ange vests are pa­trolling an 11-block stretch. Their mis­sion is to keep area school­child­ren safe from drug deal­ers, gang­bangers and other threats as the kids walk to their af­ter­school ac­tiv­i­ties.

Called the “cor­ner cap­tains,” they are the moth­ers of the stu­dents as well as other vol­un­teers par­tic­i­pat­ing in the Safe Pas­sage ini­tia­tive. Cool and col­lected, they keep watch for an hour each week­day. Ear­lier this year, an in­ter­sec­tion in this area, Turk and Leav­en­worth, was the site of a dou­ble shoot­ing on an early Mon­day af­ter­noon.

The chil­dren walk with a par­ent or in small groups along side­walks that are painted to re­sem­ble the yel­low brick road in the Wiz­ard of Oz. Some of the kids thank the vol­un­teers as they pass.

The pro­gram, part of a larger ini­tia­tive called the Ten­der­loin Health Im­prove­ment Part­ner­ship, is funded by the St. Fran­cis Foun­da­tion, the phil­an­thropic arm of St. Fran­cis Me­mo­rial Hos­pi­tal. Its lead­ers have worked to get more po­lice on the streets, and its com­mu­nity or­ga­niz­ers have ne­go­ti­ated with lo­cal gangs to keep chil­dren se­cure dur­ing the Safe Pas­sage time win­dow. The broader ini­tia­tive has re­ceived $1 mil­lion from the hos­pi­tal’s foun­da­tion in each of the past two years.

“It’s not easy, but for the most part (the gang mem­bers) do re­spect the kids,” said Pa­tri­cia Zamora, area di­rec­tor of the Boys & Girls Club of San Francisco. “Now it’s ex­pand­ing to el­derly and com­mu­nity walks, which wouldn’t have been pos­si­ble with­out

the ini­tial fund­ing. We could never get the trac­tion to sus­tain the vol­un­teers.”

Dig­nity Health, which owns St. Fran­cis Me­mo­rial, is one of a num­ber of hos­pi­tals and health sys­tems across the coun­try tar­get­ing funds to ad­dress so­ci­etal ills such as poverty, violence, hunger, poor nu­tri­tion and lack of hous­ing. While not-for-profit hos­pi­tals have al­ways been ex­pected to of­fer pro­grams that im­prove health or in­crease health­care ac­cess, that work has tra­di­tion­ally fo­cused on train­ing new doc­tors, con­duct­ing re­search and pro­vid­ing char­ity care for the poor and unin­sured. Crit­ics, joined by some health sys­tem lead­ers, ar­gue that hos­pi­tals can and should do more to ad­dress broader health is­sues in their com­mu­ni­ties.

WHILE THE NUM­BER OF HEALTH SYS­TEMS im­ple­ment­ing such ini­tia­tives is still small, lead­ers of some not-for-profit sys­tems such as As­cen­sion Health, Dig­nity, Kaiser Per­ma­nente and ProMed­ica are making the case for greater in­vest­ment in broad pub­lic health and com­mu­nity im­prove­ment pro­grams. Their pro­grams in­clude As­cen­sion’s de­vel­op­ment of a mixed-use hous­ing, re­tail and com­mu­nity space in Bal­ti­more and Toledo, and Ohiobased ProMed­ica’s part­ner­ship with the Al­liance to End Hunger to host a hunger sym­po­sium in Wash­ing­ton.

Such ef­forts are start­ing to dove­tail with those of phil­an­thropic foun­da­tions and com­mu­nity and so­cial ser­vice or­ga­ni­za­tions. “We keep back­ing up into the health­care world,” said David Erick­son, di­rec­tor of the Cen­ter for Com­mu­nity De­vel­op­ment In­vest­ments at the Fed­eral Re­serve Bank of San Francisco. “We see (hos­pi­tals) as po­ten­tial part­ners.”

While health sys­tem lead­ers cite their not-for-profit and/or re­li­gious mis­sions to help their com­mu­ni­ties as the rea­son for their pub­lic health push, they also rec­og­nize that their sys­tems face grow­ing pres­sure to jus­tify their tax-ex­empt sta­tus as their char­ity-care bur­den shrinks un­der the Af­ford­able Care Act, par­tic­u­larly in states that have ex­panded Med­i­caid un­der the law.

An­other driver is that hos­pi­tal pay­ment is evolv­ing to a pop­u­la­tion-health man­age­ment model that re­wards providers for keep­ing large groups of en­rolled pa­tients healthy. Hos­pi­tal lead­ers in­creas­ingly rec­og­nize that health and so­cial fac­tors are closely in­ter­twined, and that it pays to in­vest in broader com­mu­nity health ini­tia­tives such as neigh­bor­hood safety, nu­tri­tion and hous­ing.

“In some cases, it’s go­ing to hap­pen be­cause they re­al­ize the re­im­burse­ment is go­ing to change,” said Phillip González, who over­sees the hos­pi­tal ac­count­abil­ity project at Bos­ton-based Com­mu­nity Cat­a­lyst, an ad­vo­cacy group for af­ford­able health­care. “The more money they save, the more money they get to re­tain within the sys­tem.”

“When the pay­ments come per per­son per year to keep (peo­ple) healthy,” Erick­son said, “you start to see a real shift in think­ing.”

Yet some ob­servers aren’t con­vinced that such com­mu­nity health-im­prove­ment ef­forts will spread widely across the hos­pi­tal in­dus­try. “It ex­ists,” said Nancy Mur­phy, who coun­sels not-for-profit hos­pi­tals at ac­count­ing firm KPMG. “I’m not sure it’s ac­cel­er­at­ing.”

There’s also the ques­tion of whether hos­pi­tals are the best-equipped in­sti­tu­tions to ad­dress so­cial ills. For one thing, not-for-profit hos­pi­tals with the man­date to pro­vide com­mu­nity ben­e­fits aren’t nec­es­sar­ily lo­cated where the great­est needs are, par­tic­u­larly in many parts of the South, which have some of the worst health out­comes, said Dr. David Kindig, pro­fes­sor emer­i­tus of pop­u­la­tion health sci­ences at the Univer­sity of Wis­con­sin. For-profit providers are more com­mon in those re­gions.

If the move­ment does take off, the shift to­ward more hos­pi­tal com­mu­nity health-im­prove­ment spend­ing is likely to hap­pen faster in the 30 states that have ex­panded Med­i­caid el­i­gi­bil­ity for adults up to 138% of the fed­eral poverty level. Hos­pi­tals in those states are spend­ing less money to cover care for the unin­sured.

“In the states that have ex­panded Med­i­caid, we’re see­ing more of those dol­lars freed up,” said Robert Henkel, CEO of As­cen­sion Health, a Catholic sys­tem with fa­cil­i­ties

Crit­ics, joined by some health sys­tem lead­ers, ar­gue that hos­pi­tals can and should do more to ad­dress broader health is­sues in their com­mu­ni­ties.

in 24 states plus the Dis­trict of Columbia. “We are in­ten­tion­ally mov­ing to­ward com­mu­nity ben­e­fit.”

Half of As­cen­sion’s states have ex­panded Med­i­caid el­i­gi­bil­ity. As a re­sult, As­cen­sion’s tra­di­tional char­ity care de­clined 9.3% in fis­cal 2015. Some of those funds were shifted into cov­er­ing the un­paid por­tion of gov­ern­ment in­sur­ance pro­grams. But the St. Louis-based sys­tem also in­creased its spend­ing on com­mu­nity health ini­tia­tives by 6.2%, or $37 mil­lion.

“We will con­tinue to look at those num­bers and plan to con­tinue to in­vest more in the com­mu­nity as we see the num­ber of in­sured goes up,” Henkel said.

Bad debt at hos­pi­tals and sys­tems in ex­pan­sion states rose only 2.5% be­tween fis­cal 2013 and 2014, com­pared with 8.9% in states that did not ex­pand Med­i­caid, ac­cord­ing to a Mod­ern Health­care anal­y­sis. Mean­while, spend­ing on char­ity care and com­mu­nity sup­port—which many sys­tems re­port as one item— in­creased 11.9% in ex­pan­sion states and 5.5% in non­ex­pan­sion states dur­ing the same time pe­riod.

BE­SIDES HAV­ING CHAR­ITY-CARE MONEY freed up to spend on pub­lic health ac­tiv­i­ties, not-for-profit health sys­tems face in­creased pres­sure to demon­strate that they’re rein­vest­ing in their com­mu­ni­ties. The ACA set new stan­dards that not-for-profit hos­pi­tals must meet to re­tain their fed­eral tax-ex­empt sta­tus, in­clud­ing a com­mu­nity needs as­sess­ment that must be con­ducted ev­ery three years. The IRS also in­di­cated that it will start re­view­ing Sched­ule H tax forms on a rolling ba­sis to en­sure that hos­pi­tals are pro­vid­ing a suf­fi­cient amount of com­mu­nity ben­e­fit.

“It will start in waves, and my un­der­stand­ing is that the waves have be­gun,” KPMG’s Mur­phy said.

A July study in Health Af­fairs, us­ing data from the IRS, found that not-for-profit hos­pi­tals spent $62.4 bil­lion on com­mu­nity ben­e­fit in 2011, but that 32% of that spend­ing went to­ward Med­i­caid pay­ment short­falls. An­other 24% cov­ered char­ity care. Spend­ing on com­mu­nity health im­prove­ment to­taled $2.7 bil­lion, just 4% of the to­tal, while do­na­tions to com­mu­nity groups ac­counted for an­other $2 bil­lion, or 3%.

An­other fac­tor that could prompt greater pub­lic health-im­prove­ment spend­ing is the IRS’ re­quire­ment for more de­tailed com­mu­nity ben­e­fit re­port­ing for each hos­pi­tal, not just a re­port for the whole health sys­tem, said James Cor­bett, se­nior vice pres­i­dent of com­mu­nity health and val­ues in­te­gra­tion at Den­ver-based Cen­tura Health.

In the first half of 2015, Cen­tura, part of Ad­ven­tist Health Sys­tem, in­creased spend­ing on health and well­ness pro­grams by 14.4%. One of its pro­grams in­cludes plac­ing full-time com­mu­nity health work­ers in its hos­pi­tals’ emer­gency de­part­ments to pro­vide care-man­age­ment ser­vices and re­duce in­ap­pro­pri­ate ED use. Char­ity care fell to 5.1% of gross pa­tient ser­vice rev­enue, down from 5.7% in the prior-year pe­riod.

Hos­pi­tals aren’t just fac­ing pres­sure from the IRS. Some states and lo­cal gov­ern­ments also are more closely scru­ti­niz­ing not-for-profit com­mu­nity ben­e­fit spend­ing. Cal­i­for­nia re­cently stripped Blue Shield of Cal­i­for­nia of its tax-ex­empt sta­tus af­ter de­ter­min­ing that the in­surer did not pro­vide ad­e­quate com­mu­nity ben­e­fit. And Mor­ris­town (N.J.) Med­i­cal Cen­ter this month agreed to pay a $26 mil­lion tax set­tle­ment to the town of Mor­ris­town; this

sum­mer a state tax court de­nied the hos­pi­tal a property tax ex­emp­tion af­ter con­clud­ing that it acts like a for-profit busi­ness.

San Francisco-based Dig­nity Health in fis­cal 2015 spent 14.3% of its to­tal ex­penses on com­mu­nity ben­e­fit pro­grams, the largest chunk of which cov­ered the un­paid por­tion of Med­i­caid-cov­ered ser­vices. Cal­i­for­nia’s Med­i­caid pro­gram, called Medi-Cal, has one of the low­est pay­ment rates in the coun­try. But Dig­nity also is spend­ing more on com­mu­nity-build­ing ac­tiv­i­ties, both for the poor and the broader pop­u­la­tion. Dig­nity has three sys­temwide ini­tia­tives:

Grants to com­mu­nity or­ga­ni­za­tions to ad­dress chronic con­di­tions such as obe­sity

In­vest­ments in in­fra­struc­ture such as hous­ing, banks and other fi­nan­cial in­sti­tu­tions

A so­cial in­no­va­tions grant for Sil­i­con Val­ley en­trepreneurs who want to tackle com­mu­nity health im­prove­ment in low­in­come neigh­bor­hoods

Since 1990, Dig­nity has awarded about $50 mil­lion in grants and in­vested more than $100 mil­lion in loans through th­ese ini­tia­tives.

Dig­nity’s St. Fran­cis Me­mo­rial Hos­pi­tal, which over­looks the Ten­der­loin dis­trict from its perch on Hyde Street, de­ter­mined that lack of in­sur­ance cov­er­age or ac­cess to care was not the big­gest pub­lic health is­sue for its com­mu­nity. That’s be­cause the city and county have been sub­si­diz­ing care for the unin­sured since 2007. In­stead, the hos­pi­tal and its foun­da­tion de­cided to fo­cus on re­duc­ing in­juries from crime and ad­dress­ing the psy­cho­log­i­cal trauma of liv­ing in an un­safe neigh­bor­hood, said Ab­bie Yant, the hos­pi­tal’s vice pres­i­dent for mis­sion, ad­vo­cacy and com­mu­nity health. “That’s where our chal­lenges are,” she said.

At As­cen­sion, each of its lo­cal re­gions, which As­cen­sion calls min­istries, is ex­pected to de­velop its own Med­i­cal Mis­sion at Home events, with the goal of get­ting peo­ple who need care con­nected to the sys­tem. St. Thomas Health, an As­cen­sion sys­tem in Nashville, has been hold­ing free health and den­tal clin­ics in cen­tral Ten­nessee.

On a re­cent Satur­day morn­ing at the Nashville Mu­nic­i­pal Au­di­to­rium, a check-in line of pa­tients snaked out the door, and the au­di­to­rium’s seats were filled with peo­ple wait­ing to be seen. In a cur­tained-off space, vol­un­teer den­tists and hy­gien­ists at 22 den­tal sta­tions were per­form­ing tooth ex­trac­tions to of­fer im­me­di­ate pain re­lief. About 1,000 peo­ple were ex­pected to at­tend the health fair.

In a back­room, St. Thomas had set up foot-wash­ing sta­tions for the home­less, one of the more pop­u­lar ser­vices. The hos­pi­tal col­lects socks be­fore the event and also pro­vides shoes through a part­ner­ship with Soles4Souls. Last year, 400 pairs of shoes were given out.

At the end of each pa­tient’s visit, those who need an­other ap­point­ment are con­nected to a St. Thomas provider who can see them within the next week. The hos­pi­tal also hands out maps show­ing the lo­ca­tions of its near­est clin­ics. Ten­nessee has not ex­panded Med­i­caid, so most of the peo­ple at this free clinic are unin­sured.

Keena Kleck­ley, a heavy­set African-Amer­i­can woman with a salt-and-pep­per bob, sat at a vol­un­teer ta­ble, wait­ing to direct pa­tients from their ini­tial health screen­ing with a nurse to the treat­ment sta­tions. She had been home­less for six years when she ar­rived at a sim­i­lar free clinic event last year, de­bil­i­tated by tooth pain. “It was just a bless­ing for them to pull my teeth,” she said. “Be­cause you can’t func­tion through pain.”

While she was there, she spot­ted a ta­ble offering job ap­pli­ca­tions. She is now em­ployed as a nurse care part­ner at St. Thomas Mid­town Hos­pi­tal in Nashville. Vol­un­teer­ing at the event this year is her way of giv­ing back.

Shy and soft-spo­ken, Kleck­ley be­comes an­i­mated when talk­ing about her work with the free clinic. “God is awesome,” she said, break­ing into a smile. “You ask him for some­thing, he’ll give it.”

St. Fran­cis Me­mo­rial Hos­pi­tal and its foun­da­tion chose to fo­cus on re­duc­ing in­juries from crime and ad­dress­ing the psy­cho­log­i­cal trauma of liv­ing in an un­safe neigh­bor­hood.

THOMAS BROEN­ING

Above: St. Fran­cis Me­mo­rial Hos­pi­tal, where Ab­bie Yant, sec­ond from left, di­rects mis­sion and ad­vo­cacy pro­grams, is a ma­jor fun­der of the Safe Pas­sages pro­gram. Shown with Yant are some of the “cor­ner cap­tains” in the Safe Pas­sage pro­gram.

THOMAS BROEN­ING

The Safe Pas­sage pro­gram helps en­sure stu­dents can walk safely to af­ter-school ac­tiv­i­ties.

Source: Mod­ern Health­care sur­vey of 46 hos­pi­tals and health­care sys­tems

Hos­pi­tal spend­ing on com­mu­nity health im­prove­ment in 2013

Area res­i­dents in need of care re­ceive a range of ser­vices at As­cen­sion’s Med­i­cal Mis­sion at Home events, from vi­sion screen­ing and den­tal ex­trac­tions to job op­por­tu­ni­ties.

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