The impact of state community benefit laws on the community health orientation and health promotion services of hospitals

For-profit hospitals could play a distinctive role as anchor institutions

RATIONALE

Hospitals have a longstanding presence in United States communities and contribute to economic development and community well-being through widespread employment, purchasing and direct community engagement. Most of the data on anchor institutions to date, however, has focused on nonprofit organisations, especially nonprofit hospitals, colleges and universities. The aim of this study is to better understand if for-profit hospitals engage in explicit anchor activities, and whether these organisations adopt unique strategies in carrying out this study.

METHODS

We used an inductive, qualitative approach to understand how for-profit hospitals perceive their anchoring efforts as distinct as compared to nonprofits. We conducted in-depth interviews with 23 hospital leaders, researchers and members of advocacy organisations, representing 11 different hospital organisations and 10 communities; and used thematic analysis to generate study findings.

RESULTS

For-profit hospitals do see at least three primary differences that render them distinctive in their efforts to anchor themselves within their communities-namely, barriers that for-profits encounter that nonprofits may not; their emphasis on strategic and synergistic practices; and their status as hospitals that also support their communities economically as tax-paying entities.

CONCLUSION

With a better understanding of their unique contributions as for-profit organisations, policymakers can identify ways to leverage these hospitals to support their communities through outreach and engagement.

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.

What do nonprofit hospitals reward? An examination of CEO compensation in nonprofit hospitals

Nonprofit hospital chief executive officer (CEO) compensation has received considerable attention in light of nonprofits’ tax-favored status as well as the high costs of hospital care. Past studies have found that hospital financial performance is a significant determinant of CEO pay but nonprofit performance, including quality and charity care, are not. Using post-ACA data, we re-examine whether a variety of hospital performance measures are important determinants of nonprofit hospital CEO compensation. We found mixed evidence with respect to the significance of the association between financial performance and uncompensated care and CEO compensation. Among the other nonprofit performance measures, patient satisfaction was significantly associated with CEO compensation, but other measures were not significant determinants of CEO compensation. Our results suggest nonprofit hospitals balance their financial health against their mission when setting CEO incentives. Additional policy targeting transparency in hospital CEO compensation may be warranted to help policymakers understand the specific factors used by hospital boards to incentivize CEOs.

Variation of hospital-based adoption of care coordination services by community-level social determinants of health

BACKGROUND

Hospital investments in care coordination services and innovative delivery models represent an important source for improving care efficiency and population health.

OBJECTIVE

The aim of this study was to explore variation of hospital-initiated care coordination services and participation in Accountable Care Organizations (ACOs) by community characteristics within an organizational theory framework.

METHODS

Our main data sets included the 2015 American Hospital Association Annual Survey, Survey of Care Systems and Payment, American Community Survey, and Area Health Resource File. Two main outcomes were (a) hospital-reported initiation of care coordination practices (such as chronic disease management, post-hospital discharge continuity of care, and predictive analytics) and (b) participation in ACO models. State fixed-effects models were used to test the association between the adoption of care coordination practices and hospital characteristics, community-level sociodemographic characteristics, and health policies.

RESULTS

Hospitals with large bed size, located in urban areas, and/or with high volume of operations were more likely to adopt care coordination practices and participate in the ACO models. Hospitals serving communities with high uninsurance rates and/or poverty rates were significantly less likely to provide care coordination practices. More stringent Community Benefit Laws (CBLs) were positively associated with the implementation of care coordination practices suggesting strong normative impacts of CBLs.

CONCLUSION

Greater hospital-initiated care coordination practices and innovative ACO models were available in well-resourced areas. Policymakers may consider increasing resources for care coordination practices in rural, underserved, and high-poverty-high-uninsured areas to ensure that vulnerable populations can benefit from these services.

For-profit hospitals have a unique opportunity to serve as anchor institutions in the U.S

Hospitals serve as anchor institutions in many U.S. communities and make contributions to bolster population health and reduce preventable death. Most studies to date have focused on nonprofit hospitals, but there may be significant opportunity for for-profits to fill this role in both urban and rural communities. Using 2017-2018 data, we calculated descriptive statistics and a multivariate regression model to assess economic and health characteristics for all U.S. counties that contain for-profit as compared to nonprofit or public hospitals (n = 4,622). After controlling for hospital and county characteristics, we found a significant and positive relationship between for-profit hospital presence and higher county unemployment, higher uninsured rates, and the number of residents reporting poor/fair health. For-profit hospitals were also less likely to be located in states that had expanded Medicaid or which had certificate-of-need laws. Our findings suggest that there is substantial opportunity for for-profit hospitals to serve as anchor institutions in many U.S. communities, despite this label more traditionally being applied to nonprofit hospitals. Given that there is not currently a regular reporting mechanism for documenting the community health contributions of for-profit hospitals, policymakers and researchers should evaluate the current state of these contributions and develop incentives to encourage more anchor activities to benefit economically vulnerable communities in the U.S.

The impact of Maryland's payment reforms on hospital community benefit efforts

BACKGROUND

In 2014, Maryland established a global budget policy for all hospitals in the state. Under this policy, hospitals are incentivized to not only provide clinical care services to individual patients but also address the health needs of their broader patient population through prevention efforts and investment in the upstream social and economic factors that determine health.

PURPOSE

To better understand the incentives created for hospitals under this policy, our study assessed whether the implementation of global budgets changed the levels and patterns of Maryland hospitals' investments in community benefits.

APPROACH

Data on hospital community benefit spending from the Internal Revenue Service Form 990 Schedule H for the years 2010-2016 were utilized for this study.

RESULTS

We found that Maryland hospitals' total spending on community benefits decreased under the global budget policy. Unlike hospitals in similar states without a global budget policy, Maryland hospitals did not experience any increases in Medicaid shortfalls between 2014 and 2016. Although Maryland hospitals provided more subsidized health services, their investment in broader community health improvement activities remained unchanged.

CONCLUSION

Our analysis suggests that Maryland hospitals have shifted strategies because of the implementation of the global budget policy. The ability to report community benefit in a way that accurately considers the context and constraints of a state's policies would provide hospitals better means of communicating these efforts to stakeholders.

PRACTICE IMPLICATIONS

Our results suggest that global budgets impact the levels and patterns of hospitals' community benefit investments.

Priorities for Investing in Community Health Improvement: A Comparison of Decision Makers in Public Health, Nonprofit Hospitals, and Community Nonprofits

CONTEXT

As a result of additional requirements for tax exemption, many nonprofit hospitals have become more actively involved in community health improvement. There is an open question, however, as to how decision makers in hospitals decide which kind of improvement projects should receive priority and how hospital managers' priorities compare with those of decision makers in public health agencies and community-based nonprofits.

OBJECTIVE

To understand the priorities that guide decision makers in public health, nonprofit hospitals, and community nonprofits when allocating resources to community health projects.

DESIGN

We conducted an online survey with a discrete choice experiment, asking respondents to choose between different types of community health projects, which varied along several project characteristics. Respondents included managers of community health and community benefit at nonprofit hospitals (n = 225), managers at local public health departments (n = 200), and leaders of community nonprofits (n = 136). Respondents were located in 47 of 50 US states. A conditional logit model was used to estimate how various project characteristics led to greater or lesser support of a given health project. Open-ended questions aided in interpretation of results.

RESULTS

Respondents from all 3 groups showed strong agreement on community health priorities. Projects were more likely to be selected when they addressed a health issue identified on community health needs assessment, involved cross-sector collaboration, or were supported by evidence. Project characteristics that mattered less included the time needed to measure the project's impact and the project's target population.

CONCLUSION

Elements often considered central to community health, such as long-term investment and prioritizing vulnerable populations, may not be considered by decision makers as important as other aspects of resource allocation. If we want greater priority for ideas such as health equity and social determinants of health, it will take a concerted effort from practitioners and policy makers to reshape expectations.

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.

Defining hospital community benefit activities using Delphi technique: A comparison between China and the United States

Introduction

Currently there is no expert consensus regarding what activities and programs constitute hospital community benefits. In China, the hospital community benefit movement started gaining attention after the recent health care system reform in 2009. In the United States, the Internal Revenue Service and the nonprofit hospital sector have struggled to define community benefit for many years. More recently, under the Affordable Care Act (ACA)’s new “community benefit” requirements, nonprofit hospitals further developed these benefits to qualify for 501(c)(3) tax exempt status.

Methods

The Delphi survey method was used to explore activities and/or programs that are considered to be hospital community benefits in China and the United States. Twenty Chinese and 19 American of academics, senior hospital managers and policy makers were recruited as experts and participated in two rounds of surveys. The survey questionnaire was first developed in China using the 5-point Likert scale to rate the support for certain hospital community benefits activities; it was then translated into English. The questionnaires were modified after the first round of Delphi. After two rounds of surveys, only responses with a minimum of 70 percent support rate were accepted by the research team.

Results

Delphi survey results show that experts from China and the U.S. agree on 68.75 percent of HCB activities and/ or programs, including emergency preparedness, social benefit activities, bad debt /Medicaid shortfall, disaster relief, environmental protection, health promotion and education, education and research, charity care, medical services with positive externality, provision of low profit services, and sliding scale fees.

Conclusions

In China, experts believe that healthcare is a “human right” and that the government has the main responsibility of ensuring affordable access to healthcare for its citizens. Meanwhile, healthcare is considered a commodity in the U.S., and many Americans, especially those who are vulnerable and low-income, are not able to afford and access needed healthcare services. Though the U.S. government recognized the importance of community benefit and included a section in the ACA that outlines new community benefit requirements for nonprofit hospitals, there is a need to issue specific policies regarding the amounts and types of community benefits non-profit hospitals should provide to receive tax exemption status.

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.

Developing Data to Support Effective Coordination of Nonprofit Hospital Community Benefit Investments

EXECUTIVE SUMMARY

Nonprofit hospitals achieve tax exemption through community benefit investments. The objective of this study was to characterize urban and suburban nonprofit hospitals' community benefit expenditures and to estimate regional per capita community benefit spending relative to community need. Community benefit expenditures, both overall and by subtype, were compared for urban versus suburban nonprofit hospitals in a large metropolitan area, the greater Philadelphia region. Estimated zip code-level per capita expenditures were mapped in the urban core area. We found that urban hospitals report higher overall community benefit expenditures than suburban hospitals yet invest less in community health improvement services, both proportionally and absolutely, despite spending similar proportions on charity care. There is an overlap in hospital-identified community benefit service areas in the urban core, but the degree of overlap is not related to community poverty levels. There is significant variation in zip code-level per capita community benefit expenditures, which does not correlate with community need. Community benefit investments offer the potential to improve community health, yet without regional coordination, the ability to maximize the potential of these investments is limited. This study's findings highlight the need to implement policies that increase transparency, accountability, and regional coordination of community benefit spending.

State-Level Community Benefit Regulation and Nonprofit Hospitals' Provision of Community Benefits

Do nonprofit hospitals provide enough community benefits to justify their tax exemptions? States have sought to enhance nonprofit hospitals' accountability and oversight through regulation, including requirements to report community benefits, conduct community health needs assessments, provide minimum levels of community benefits, and adhere to minimum income eligibility standards for charity care. However, little research has assessed these regulations' impact on community benefits. Using 2009-11 Internal Revenue Service data on community benefit spending for more than eighteen hundred hospitals and the Hilltop Institute's data on community benefit regulation, we investigated the relationship between these four types of regulation and the level and types of hospital-provided community benefits. Our multivariate regression analyses showed that only community health needs assessments were consistently associated with greater community benefit spending. The results for reporting and minimum spending requirements were mixed, while minimum income eligibility standards for charity care were unrelated to community benefit spending. State adoption of multiple types of regulation was consistently associated with higher levels of hospital-provided community benefits, possibly because regulatory intensity conveys a strong signal to the hospital community that more spending is expected. This study can inform efforts to design regulations that will encourage hospitals to provide community benefits consistent with policy makers' goals.

The Impact of IRS Tax Policy on Hospital Community Benefit Activities

The Internal Revenue Service (IRS) recently introduced tax code revisions requiring stricter oversight of community benefit activities (CBAs) conducted by tax-exempt, not-for-profit hospitals. We examine the impact of this tax requirement on CBAs among these hospitals relative to for-profit and government hospitals that were not subject to the new policy. We employed a quasi-experimental, difference-in-difference study design using a longitudinal observational approach and used secondary data collected by the American Hospital Association (years 2006-2010 including 20,538 hospital year observations). Findings show a significant increase in the reporting of 7 of the 13 CBAs among tax-exempt, not-for-profit hospitals compared with other hospitals after the policy change. Examples include partnering to conduct community health assessments ( b = 0.035, p = .002) and using capacity assessments to identify unmet community health needs ( b = 0.041, p = .001). Recent tax revisions are associated with increases in reported CBAs among tax-exempt, not-for-profit hospitals. As the debate continues regarding tax exemption status for not-for-profit hospitals, policy makers should expand efforts for enhanced accountability.

Community benefits provided by religious, other nonprofit, and for-profit hospitals: a longitudinal analysis 2000-2009

BACKGROUND

Nonprofit hospitals (NFPs) are expected to provide community benefits to justify the tax benefits they receive, but recent budgetary constraints have called into question the degree to which the tax benefits are justified. The empirical literature comparing community benefits provided by NFPs and their for-profit counterparts is mixed. However, NFPs are not a homogenous group and can include religious hospitals, community-owned hospitals, or academic medical centers.

PURPOSE

This longitudinal study examines how religious hospitals compare with other NFPs and for-profit hospitals with respect to providing community benefits and how the provision of community benefits by hospitals has changed over time.

METHODOLOGY

Using a pooled cross-sectional design, we examine two summated scores based on questions from the American Hospital Association annual survey that focus on community orientation among hospitals. We analyze two regressions with year, facility, and market controls to determine how religious hospitals compare with the other groups over time.

FINDINGS

Overall, 11% of U.S. hospitals are religious. Religious hospitals were more likely to engage in each individual community benefit activity examined. In addition, the mean values of community benefits provided by religious hospitals, as measured on two summated scores, were significantly higher than those provided by other hospital types in bivariate and regression analyses. Overall, community benefits provided by all hospitals increased over time and then leveled off during the start of the recent economic downturn.

PRACTICE IMPLICATIONS

As the debate continues regarding federal tax exemption status, policymakers should consider religious hospitals separately from NFPs. Managers at religious hospitals should consider how their increased levels of community benefits are related to their missions and set benchmarks that recognize and communicate those achievements.

Do hospitals cross-subsidize?

Despite its salience as a regulatory tool to ensure the delivery of unprofitable medical services, cross-subsidization of services within hospital systems has been notoriously difficult to detect and quantify. We use repeated shocks to a profitable service in the market for hospital-based medical care to test for cross-subsidization of unprofitable services. Using patient-level data from general short-term hospitals in Arizona and Colorado before and after entry by cardiac specialty hospitals, we study how incumbent hospitals adjusted their provision of three uncontested services that are widely considered to be unprofitable. We estimate that the hospitals most exposed to entry reduced their provision of psychiatric, substance-abuse, and trauma care services at a rate of about one uncontested-service admission for every four cardiac admissions they stood to lose. Although entry by single-specialty hospitals may adversely affect the provision of unprofitable uncontested services, these findings warrant further evaluation of service-line cross-subsidization as a means to finance them.

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.

The impact of the individual mandate and Internal Revenue Service Form 990 Schedule H on community benefits from nonprofit hospitals

In response to a growing concern that nonprofit hospitals are not providing sufficient benefit to their communities in return for their tax-exempt status, the Internal Revenue Service (IRS) now requires nonprofit hospitals to formally document the extent of their community contributions. While the IRS is increasing financial scrutiny of nonprofit hospitals, many provisions in the recently passed historical health reform legislation will also have a significant impact on the provision of uncompensated care and other community benefits. We argue that health reform does not render the nonprofit organizational form obsolete. Rather, health reform should strengthen the nonprofit hospitals' ability to fulfill their missions by better targeting subsidies for uncompensated care and potentially increasing subsidized health services provision, many of which affect the public's health.

Hospitals' health promotion services in their communities: findings from a literature review

BACKGROUND

Hospitals have long had an important role in the health of communities and the nation. Health promotion (HP) has gained attention in American health and will become more important with the 2010 health reform legislation. Many U.S. hospitals provide HP services in their communities, and hospital leaders are accountable for HP.

PURPOSES

This article uses a systematic review of research literature to answer three questions about U.S. hospitals' HP services in their communities: (a) What are the characteristics of hospitals that offer HP services? (b) What are the reasons that hospitals offer HP services? And (c) what are the implementation processes hospitals use to offer HP services?

METHODOLOGY/APPROACH

Authors used search criteria and found 255 articles published between 1985 and 2009. Inclusion/exclusion criteria were applied to screen and select articles, and 25 articles were kept and reviewed. Authors independently completed a standard data extraction form for each article, combined and reconciled their data, and created a database of findings.

FINDINGS

Hospital size was positively associated with HP, as were participation in systems, alliances, and networks. Communities' median income, existing HP, population younger than 65 years, population above poverty, and employment levels were positively related to hospitals' HP. Relationships with hospital ownership, managed care, and competition were less clear. External norms, HP diffusion, and mimetic behavior were reasons for hospitals' HP; community benefit laws were less important. To implement HP, hospitals applied management methods, shared resources, collaborated with community organizations, and used a variety of HP methods.

PRACTICE IMPLICATIONS

Collaboration and linkages with other organizations enable hospitals to expand HP. Hospitals should apply management methods (not just HP methods) to effectively offer HP services. Support for small hospitals' HP is needed.

Uncompensated care provided by for-profit, not-for-profit, and government owned hospitals

Background

There is growing concern certain not-for-profit hospitals are not providing enough uncompensated care to justify their tax exempt status. Our objective was to compare the amount of uncompensated care provided by not-for-profit (NFP), for-profit (FP) and government owned hospitals.

Methods

We used 2005 state inpatient data (SID) for 10 states to identify patients hospitalized for three common conditions: acute myocardial infarction (AMI), coronary artery bypass grafting (CABG), or childbirth. Uncompensated care was measured as the proportion of each hospital's total admissions for each condition that were classified as being uninsured. Hospitals were categorized as NFP, FP, or government owned based upon data obtained from the American Hospital Association. We used bivariate methods to compare the proportion of uninsured patients admitted to NFP, FP and government hospitals for each diagnosis. We then used generalized linear mixed models to compare the percentage of uninsured in each category of hospital after adjusting for the socioeconomic status of the markets each hospital served.

Results

Our cohort consisted of 188,117 patients (1,054 hospitals) hospitalized for AMI, 82,261 patients (245 hospitals) for CABG, and 1,091,220 patients for childbirth (793 hospitals). The percentage of admissions classified as uninsured was lower in NFP hospitals than in FP or government hospitals for AMI (4.6% NFP; 6.0% FP; 9.5% government; P < .001), CABG (2.6% NFP; 3.3% FP; 7.0% government; P < .001), and childbirth (3.1% NFP; 4.2% FP; 11.8% government; P < .001). In adjusted analyses, the mean percentage of AMI patients classified as uninsured was similar in NFP and FP hospitals (4.4% vs. 4.3%; P = 0.71), and higher for government hospitals (6.0%; P < .001 for NFP vs. government). Likewise, results demonstrated similar proportions of uninsured patients in NFP and FP hospitals and higher levels of uninsured in government hospitals for both CABG and childbirth.

Conclusions

For the three conditions studied NFP and FP hospitals appear to provide a similar amount of uncompensated care while government hospitals provide significantly more. Concerns about the amount of uncompensated care provided by NFP hospitals appear warranted.

The contribution of hospitals and health care systems to community health

This article reviews evidence on hospitals' and health systems' impacts on community health improvement. We begin with an overview of the history of community benefit and then discuss the lack of a widely accepted definition and measurement of community benefit activities as well as the expectations and accountability of tax-exempt not-for-profit hospitals and health systems in community initiatives. We highlight the approaches of two systems and identify strategic, cultural, technical, and structural challenges associated with increasing community benefit and health-improvement activities. We conclude by offering recommendations for policy and practice.

How do system-affiliated hospitals fare in providing community benefit?

The shift from local, community-based organizations to more complex delivery systems raises questions about the community orientation and accountability of health systems and their affiliates. This study examines whether hospitals affiliated with health care systems are more or less likely to engage in practices that reflect responsibility to their local communities by providing benefits in the form of uncompensated care, community engagement, Medicaid caseload, and accessible pricing policies. Using audited state data and other sources, we performed a longitudinal analysis on a pooled cross-sectional data file for the years 1989-2003 for all hospitals in Texas, California, and Florida. Results indicate that when compared to independent hospitals, system affiliation is associated with less community benefit. However, the level of community benefit varies depending on the type of community benefit examined and the structural characteristics of the system with which a hospital is affiliated. Results further suggest that the level and type of community benefit is conditioned by the market under which system-affiliated hospitals operate.