Community benefit laws, hospital ownership, community orientation activities, and health promotion services

Provision of Social Care Services by US Hospitals

Policy Points Hospitals address population health needs and patients' social determinants of health by offering social care services. Tax-exempt hospitals are required to invest in community benefits, including social care services programs, though most community benefits spending is toward unreimbursed health care services. Tax-exempt hospitals offer about 36% more social care services than for-profit hospitals. Among tax-exempt hospitals, those that allocate more resources to community benefits spending offer more types of social care services, but those in states with minimum community benefits spending requirements offer fewer social care services. Policymakers may consider specifically incentivizing community benefits expenditures toward particular social care services, including linking tax exemptions to implementation, utilization, and outcome targets, to more directly help patients.

CONTEXT

Despite growing interest in identifying patients' social needs, little is known about hospitals' provision of services to address them. We identify social care services offered by US hospitals and determine whether hospital spending or state policies toward community benefits are associated with the provision of these services by tax-exempt hospitals.

METHODS

National secondary data about hospitals were collected from the American Hospital Association Annual Survey, with additional Internal Revenue Service (IRS) Form 990 data on community benefits spending from CommunityBenefitInsight.org and state-level community benefits policies from HilltopInstitute.org. Descriptive statistics for types of social care services and hospital characteristics were calculated, with bivariate chi-square and t-tests comparing for-profit and tax-exempt hospitals. Multivariable Poisson regression was used to estimate associations between hospital characteristics and types of services offered and among tax-exempt hospitals to estimate associations between social care services and community benefits spending and policies. Multivariable logistic regressions modeled associations between community benefits spending/policies and each type of social care services.

FINDINGS

Private US hospitals offered an average of 5.7 types of social care services in 2018. Tax-exempt hospitals offered about 36% more social care services than for-profit hospitals. Larger number of beds, health system affiliation, and having community partnerships are associated with more social care services, whereas rural hospitals and those managed under contract offered fewer social care services. Among tax-exempt hospitals, greater community benefits spending is associated with offering more total (incidence rate ratio [IRR] = 1.10, p < 0.01) and patient-focused social care services (IRR = 1.16, p < 0.01). Hospitals in states with minimum community benefits spending requirements offered significantly fewer social care services.

CONCLUSIONS

Although tax-exempt status and increased community benefits spending were associated with increased social care services provision, the observation that certain hospital characteristics and state minimum community benefits spending requirements were associated with fewer social care services suggests opportunities for policy reform to increase social care services implementation.

State Regulation and Hospital Community Benefit Spending in Medicaid Expansion States

CONTEXT

Previous studies show that nonprofit hospital spending on charity care declined in Medicaid expansion states. We test whether state community benefit regulations mitigated the decline in charity care spending.

METHODS

We use a fixed effects model to evaluate the association between state regulations and nonprofit hospital community benefit spending and its subcategories as a share of total expenses in Medicaid expansion states. We obtained community benefit spending data from the Internal Revenue Service Form 990 Schedule H filings of 1,738 hospitals in 44 states and the District of Columbia from 2010 to 2017. We determine the stringency of state regulations by comparing the provisions of state and federal requirements based on regulation information compiled by the Hilltop Institute.

FINDINGS

State minimum community benefit requirements are associated with increased community benefit and charity care spending by nonprofit hospitals in Medicaid expansion states.

CONCLUSIONS

States that imposed minimum community benefit requirements on nonprofit hospitals did not experience a decline in charity care spending after Medicaid expansion. The results suggest state minimum community benefit rules may expand the provision of community benefit and charitable care spending.

The Changing Landscape of Catholic Hospitals and Health Systems, 2008-2017

EXECUTIVE SUMMARY

More than 600 Catholic hospitals operating in the United States face pressures for efficiency and effectiveness as well as compliance with demands of the Roman Catholic Church. They have responded to the pressures in various ways that have led to mixed models of organizational ownership and management. The purpose of this study was to describe and analyze the status of Catholic hospital ownership and management, especially the strategic and structural features of the parent health systems. Longitudinal data (2008-2017) were acquired and analyzed using repeated-measures analysis. Descriptive statistics were prepared using cross-sectional matched pairing for 2008 and 2017 data. Of 4,253 hospitals studied, 534 changed ownership or management. More Catholic Church-operated hospitals, regardless of type of ownership (for-profit, not-for-profit, church), became decentralized to a greater degree over the 8-year period and took on more attributes of non-Catholic hospitals.The 21st century Catholic hospital is more likely to be partnered with a non-Catholic hospital or to be owned by a for-profit system than to be solely partnered with or operated by another Catholic system. Today's Catholic hospitals appear to be more similar to their non-Catholic counterparts. With the trend toward larger systems that comprise more diverse partners, an increase in lay oversight could lead to further movement away from Catholic identity and the original mission of a hospital. As systems grow in size but shrink in number, administrators must make difficult decisions about the type and scope of services offered as well as the partners they need to deliver their services.

Community Orientation Scale among Community Health Nurses in Fiji: Scale development and psychometric evaluation

Aim

To develop and evaluate the reliability and validity of the COSCHN, a scale that aims to measure community orientation among community health nurses in Fiji.

Design

Descriptive cross-sectional design.

Methods

A self-administered questionnaire that included the 51 items in the preliminary COSCHN was distributed to community health nurses in Fiji from April-July 2016.

Results

Exploratory factor analysis of 226 responses (77.4% response rate) to the COSCHN revealed 30 items loading on four factors: Community Initiative Promotion, Consensus Building for Community Needs and Activity Goal, Commitment towards Work and Community Members and Mutually Trusting Relationships with Community Members towards Empowerment. Confirmatory factor analysis with high-order factor modelling revealed a reasonable fit to the data. Cronbach's α values for the COSCHN and the four factors ranged from 0.78-0.94. Weak correlations were noted for concurrent validity, while known-groups validity and time stability were generally satisfactory.

The Importance of Governmental and Nongovernmental Investments in Public Health and Social Services for Improving Community Health Outcomes

OBJECTIVE

To explore whether health outcomes are influenced by both governmental social services spending and hospital provision of community health services.

DESIGN

We combined hospital provision of community health services data from the American Hospital Association with local governmental spending data from the US Census Bureau. Longitudinal models regressed community health outcomes for 2012-2016 on local government spending on health, social services, and education from 5 years previously, controlling for sociodemographic and hospital marketplace characteristics, spatial autocorrelation, and state-level random effects. For counties with hospitals, models also included county-level data on hospitals' provision of community health services.

SETTING

All analyses were performed at the county level for US counties between 2012 and 2016.

PARTICIPANTS

Complete spending, hospital, and health outcomes data were available for a total of 2379 counties.

MAIN OUTCOME MEASURES

We examined relationships between governmental spending, hospital service provision, and 5 population health outcome measures: years of potential life lost prior to age 75 years per 100 000 population, percentage of population in fair or poor health, percentage of adults who are physically inactive, deaths due to injury per 100 000 population, and percentage of births that are of low birth weight.

RESULTS

Governmental investments in health, social services, and education positively impacted key health outcomes but mainly in counties with 1 or more hospitals present. Hospitals' provision of community health services also had a significant positive impact on health outcomes.

CONCLUSIONS

Hospital provision of community health services and increases in local governmental health and social services spending were both associated with improved health. Collaboration between local governments and hospitals may help ensure that public and private community health resources synergistically contribute to the public's health. Local policy makers should consider service provision by the private sector to leverage the public investments in health and social services.

Organizational and environmental factors influencing hospital community orientation

BACKGROUND

Community orientation refers to hospitals' efforts to assess and meet the health needs of the local population. Variations in the number of community orientation-related activities offered by hospitals may be attributed to differences in organizational and environmental characteristics. Therefore, hospitals have to strategically respond to these internal and external constraints to improve community health. Understanding the facilitators and barriers of hospital community orientation is important to health care managers facing pressure from the external environment to meet the expectations of the community as well as Affordable Care Act guidelines.

PURPOSE

The purpose of this study was to examine the organizational and environmental factors that promote or impede hospital community orientation.

METHODOLOGY

A multivariate regression with random effects was conducted using data from the American Hospital Association Annual Survey from 2007 to 2010 and county level data from the Area Health Resource Files.

FINDINGS

Not-for-profit, system-affiliated, network-affiliated, and larger hospitals have a higher degree of community orientation. In addition, the percentage of the county residents under the age of 65 years with health insurance and hospitals in states with certificate-of-need laws were also positively related to the degree of community orientation. During the study period, it appears that organizational factors mattered more in determining the degree of community orientation.

PRACTICE IMPLICATIONS

Overall, a better understanding of the factors that influence community orientation can assist hospital administrators and policymakers in stimulating the hospital's role in improving population health and its responsiveness to community health needs. These efforts may occur by building interorganizational relationships or by incentivizing those hospitals that are least likely to be community oriented.

Government Health and Social Services Spending Show Evidence of Single-Sector Rather Than Multi-Sector Pursuit of Population Health

Population health improvements can be achieved through work made possible by government spending on health care, public health, and social services. The extent to which spending allocations across these sectors is synergistic with or trade-off against one another is unknown. Achieving a balanced portfolio with multi-sector contributions is key to improving health outcomes. This study tested competing hypotheses regarding achievement of balanced multi-sector resources for health. County-level U.S. Census Bureau data on all local governmental spending measured each county’s average per capita local government spending for public hospitals, public health, social services, and education. American Hospital Association (AHA) Annual Survey data on hospital community health service provision were used to calculate an index of hospital community service provision aggregated to county level by year. County Health Rankings data measured each county’s health outcomes and health factors. Longitudinal mixed-effects regression models (n = 1877 counties) predicted changes in spending for each government spending category based on two sets of predictors (government spending vs community health services and needs) from current and prior year. Models account for average spending in each category and county-, state-, and time-trends. Models showed that spending increases in each of the four spending categories examined (public hospitals, public health, social services, and education) were not associated with changes in spending across other categories in current or prior years. For all categories, an increase from baseline spending levels in Year 1 was always significantly associated with an increase from baseline spending level in that same category in Year 2 (ie, spending stayed above baseline in Year 2). Multi-sector initiatives to health outcomes require funding across sectors, yet there was little evidence to suggest that communities that invest in public hospitals, public health, or other social services see commensurate increases in other areas. Underlying funding decisions may reflect strategic decisions within a community to scale up single sectors, constrained resources for multi-sector scale up, or a host of additional factors not measured here.

Assessing the validity of self-reported community benefit expenditures: evidence from not-for-profit hospitals in California

CONTEXT

In its revised Form 990 Schedule H, the Internal Revenue Service requires not-for-profit hospitals to provide detailed financial information on their community benefits, yet no standardized reporting guidelines exist for how these activities should be quantified. As a result, little is known currently about whether a hospital's self-reported community benefit expenditures provide an accurate picture of its commitment to serving the community.

OBJECTIVE

To assess the validity of hospitals' self-reported community benefit expenditures.

DATA AND METHODS

Data for this study came from California hospitals. Self-reported community benefit expenditures were derived from hospitals' annual community benefit reports for the year 2009. Bivariate correlation analysis was used to compare self-reported expenditures to a set of indicators of hospitals' charitable activity. Of the 218 private, not-for-profit California hospitals that were required to submit community benefit reports for 2009, 91 (42%) provided sufficient information for our analysis.

RESULTS

California hospitals' self-reported community benefit expenditures were strongly correlated with indicators of charitable activity. Hospitals that reported higher community benefit expenditures engaged in more charitable activities than hospitals that reported lower levels of community benefit spending.

CONCLUSION

Expenditure information from California hospitals' community benefit reports was found to be a valid indicator of charitable activity. Self-reported community benefit spending may thus provide a fairly accurate picture of a hospital's commitment to serving its community, despite the lack of standardized reporting guidelines.