Nonprofit Hospital Community Benefit in the U.S.: A Scoping Review From 2010 to 2019

Chaplains' reports of integration in community health initiatives: a qualitative study

Health care and religious organizations have a long history with one another. Chaplains' investments in the health and wellbeing of their local communities have extended beyond the hospital walls for longer than many chaplains may recognize. However, the published evidence suggests these efforts have been limited. Given the history of health care evolution in the United States, the small evidence of cases highlighting chaplains' leadership within community health initiatives, and the pressure for health systems to address the social determinants of health, we sought to explore chaplains' integration in community health and wellness initiatives. This paper presents the results of a qualitative analysis of interviews with chaplains working to promote community health and wellness (n = 10). The identified themes highlight factors at the individual chaplain level, such as how chaplains got involved, characteristics of the chaplains' contexts, and the impact of chaplains' involvement.

Addressing Social Needs in Clinical Settings: Implementation and Impact on Health Care Utilization, Costs, and Integration of Care

In recent years, health care policy makers have focused increasingly on addressing social drivers of health as a strategy for improving health and health equity. Impacts of social, economic, and environmental conditions on health are well established. However, less is known about the implementation and impact of approaches used by health care providers and payers to address social drivers of health in clinical settings. This article reviews current efforts by US health care organizations and public payers such as Medicaid and Medicare to address social drivers of health at the individual and community levels. We summarize the limited available evidence regarding intervention impacts on health care utilization, costs, and integration of care and identify key lessons learned from current implementation efforts.

A national overview of nonprofit hospital community benefit programs to address the social determinants of health

Decades of research have solidified the crucial role that social determinants of health (SDOH) play in shaping health outcomes, yet strategies to address these upstream factors remain elusive. The aim of this study was to understand the extent to which US nonprofit hospitals invest in SDOH at either the community or individual patient level and to provide examples of programs in each area. We analyzed data from a national dataset of 613 hospital community health needs assessments and corresponding implementation strategies. Among sample hospitals, 69.3% (n = 373) identified SDOH as a top-5 health need in their community and 60.6% (n = 326) reported investments in SDOH. Of hospitals with investments in SDOH, 44% of programs addressed health-related social needs of individual patients, while the remaining 56% of programs addressed SDOH at the community level. Hospitals that were major teaching organizations, those in the Western region of the United States, and hospitals in counties with more severe housing problems had greater odds of investing in SDOH at the community level. Although many nonprofit hospitals have integrated SDOH-related activities into their community benefit work, stronger policies are necessary to encourage greater investments at the community-level that move beyond the needs of individual patients.

Evaluation of Community Benefit Activities Among Nonprofit Hospitals, 2018-2021

OBJECTIVE

This study examined approaches that nonprofit hospitals use to evaluate community benefit activities in the Community Health Needs Assessment/Implementation Plan (CHNA/IP) process.

DESIGN

Content analysis of CHNAs/IPs completed between 2018 and 2021 from a 20% stratified random sample (n = 503) of US nonprofit hospitals.

MAIN OUTCOME MEASURES

A coding sheet was used to record details about the evaluation content reported by hospitals in their CHNAs/IPs. Evaluation was coded into 4 categories: (1) no mention of evaluation; (2) description of evaluation without reporting any measures; (3) reporting reach (number of people served) only; and (4) reporting social/health outcomes. For logistic regression analyses, categories 1 and 2 were grouped together into "no evaluation measures" and categories 3 and 4 were grouped into "evaluation measures" for binary comparison. Multinomial logistic regression was also used to individually examine categories 3 and 4 compared with no evaluation measures.

RESULTS

While a majority of nonprofit hospitals (71.4%, n = 359) mentioned evaluation in their CHNAs, almost half (49.7%, n = 250) did not report any evaluation measures. Among the 50.3% (n = 253) of hospitals that reported evaluation measures, 67.2% (n = 170) only reported reach. Fewer than 1 in 5 hospitals (16.5%, n = 83) reported social/health outcomes. Hospitals that hired a consultant (adjusted odds ratio [AOR] = 1.61; 95% confidence interval [CI], 1.08-2.43) and system members (AOR = 1.76; 95% CI, 1.12-2.75) had higher odds of reporting evaluation measures. Using hospitals that reported no measures as the base category, system members (AOR = 7.71; 95% CI, 2.97-20.00) also had significantly higher odds of reporting social/health outcomes, while rural locations had lower odds (AOR = 0.43; 95% CI, 0.20-0.94).

CONCLUSIONS

Although hospitals are required to evaluate the impact of actions taken to address the health needs identified in their CHNAs, few hospitals are reporting social/health outcomes of such activities. This represents a missed opportunity, as health/social outcomes could be used to inform the allocation of resources to maximize community benefits and the expansion of successful community initiatives.

An action research partnership in an urban Texas county to explore barriers and opportunities for collaborative community health needs assessments

Background

The Affordable Care Act mandated triennial community health needs assessments (CHNAs) for greater nonprofit hospital accountability in responding to community health needs. Over 10 years later, hospital spending on community benefits remains largely unchanged. While greater collaboration in CHNA implementation can increase hospital investment in community-based initiatives, nonprofit hospitals in conservative states are subject to policy, political, and economic factors that inhibit public health partnerships and magnify existing disparities in health care access. This participatory action research study explores the decision-making environment of collaborative CHNA implementation within a group of nonprofit hospitals in a north Texas urban county.

Methods

In 2017 faculty from an urban anchor institution initiated an academic-community partnership with a coalition of nonprofit hospitals, public health departments, and academic institutions. An interdisciplinary research team engaged in multi-method document review and qualitative data collection to describe historical barriers for local CHNA processes and develop practical strategies for joint CHNA initiatives. Local CHNA documents were first reviewed through team-based content analysis and results applied to develop a qualitative study protocol. Key informants were recruited from county-based nonprofit hospitals, community-based nonprofit organizations, and public health systems. Seventeen senior- and mid-level professionals participated in semi-structured research interviews to describe their perspectives relating to CHNA-related planning and implementation decisions. Through iterative data collection and analysis, the research team explored CHNA-related knowledge, experiences, and processes. A constructivist lens was subsequently applied to examine historical barriers and future opportunities for local collaboration.

Results

Findings reveal CHNA implementation is a multi-stage cyclical process in organizational environments with accountability to a wide range of public and private stakeholders. This promotes varied levels of inclusivity and conservatism in data collection and community benefit implementation. Decisions to collaborate are hindered by competing priorities, including compliance with existing guidelines, administrative simplicity, alignment with health care service delivery, and efficient resource use. Efforts to promote greater CHNA collaboration may be facilitated through intentional alignment with organizational priorities and clearly communicated benefits of participation for leaders in both public and private nonprofit health systems.

Discussion

We consider implications for policymakers and health systems in restrictive political environments and advance a conceptual framework for greater CHNA collaboration.

Interventions to address global inequity in diabetes: international progress

Diabetes is a serious chronic disease with high associated burden and disproportionate costs to communities based on socioeconomic, gender, racial, and ethnic status. Addressing the complex challenges of global inequity in diabetes will require intentional efforts to focus on broader social contexts and systems that supersede individual-level interventions. We codify and highlight best practice approaches to achieve equity in diabetes care and outcomes on a global scale. We outline action plans to target diabetes equity on the basis of the recommendations established by The Lancet Commission on Diabetes, organising interventions by their effect on changing the ecosystem, building capacity, or improving the clinical practice environment. We present international examples of how to address diabetes inequity in the real world to show that approaches addressing the individual within a larger social context, in addition to addressing structural inequity, hold the greatest promise for creating sustainable and equitable change that curbs the global diabetes crisis.

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.

Community Engagement in Nonprofit Hospital Community Health Needs Assessments and Implementation Plans

CONTEXT

Nonprofit hospitals are required to provide community benefits in exchange for their tax-exempt status. This includes a community health needs assessment (CHNA) to identify community needs and an implementation plan (IP) with strategies to address top needs every 3 years. In addition, hospitals are required to engage community members in these assessments.

OBJECTIVE

The objective of this study was to explore community engagement and representation in CHNAs and IPs.

DESIGN

The researchers conducted a content analysis of CHNAs and IPs from a nationally representative sample of 503 nonprofit hospitals between 2018 and 2021.

MAIN OUTCOME MEASURES

For CHNAs, a coding sheet was used to record the types of community members engaged by hospitals. For IPs, the team coded whether community engagement was reported at all and then performed an in-depth analysis to identify categories of community members, engagement methods used, and roles of community input. Finally, frequencies of categories across IPs were quantified.

RESULTS

Eighty-nine percent of hospitals (n = 449) engaged community members in their CHNA, but only 14% (n = 71) engaged community members in their IP. An in-depth look at these IPs found that hospitals engaged underserved/minority populations, low-income populations, high school students, public health experts, and stakeholder organizations. Community members were involved in multiple steps, including brainstorming ideas, narrowing down needs, developing strategies, and reacting to proposed strategies.

CONCLUSIONS

Although IPs are intended to benefit the community, there is a lack of community involvement reported in IPs. Hospitals may need incentives, resources, and personnel support to ensure representation of community members throughout the entire CHNA and IP process.

Equity as a Guiding Theme in Hospitals' Community Health Needs Assessments

INTRODUCTION

This study explores the relationship between nonprofit hospitals' use of equity as a guiding theme in the development of their community health needs assessments and the level of alignment between the health needs identified in the community health needs assessment and those addressed in hospitals' implementation strategy.

METHODS

Using data from a nationally representative data set of 485 nonprofit hospital community health needs assessments for the years 2018-2021, this study employed a multivariate logistic regression model to examine the association between hospitals' use of equity as a guiding theme in the community health needs assessment and binary indicators of alignment for 6 common community health needs: access to care, chronic illness, obesity, mental health, substance use, and social determinants of health.

RESULTS

Hospitals using equity as a guiding theme in their community health needs assessment reported significantly greater alignment for 3 needs: access to care (OR=3.40), substance use (OR=2.75), and social determinants of health (OR=3.60).

CONCLUSIONS

Using equity as a guiding theme in the needs assessment process can help to align hospitals' community health initiatives with the most pressing health needs, thus contributing to public health improvement.

One Decade Later: The Generalizability, Diversity, and Inclusion of Community Health Needs Assessments

CONTEXT

The 2010 Patient Protection and Affordable Care Act aimed to reduce health disparities and change medicine to be more community-driven. To maintain tax-exempt status, hospitals must complete a Community Health Needs Assessment (CHNA) every 3 years. This assessment must ( a ) integrate input from individuals the community serves, ( b ) make the report publicly assessable, and ( c ) adopt an implementation strategy based on community health needs identified in the assessment. However, there is little information on how representative CHNAs are of the community.

DESIGN

A content analysis was performed on a random sample of CHNA reports.

SETTING

This investigation examined nonprofit hospitals across the United States.

OBJECTIVES

This investigation analyzed the quality of CHNAs and described existing CHNA practices through 4 means: (1) identified the type of data included; (2) examined the frequency in the methods of data collection; (3) understood how representative those data are of the hospital's service region; and (4) explored to what extent the hospital addressed diversity and inclusion such as through recruitment.

METHODS

A stratified random sample was drawn of CHNAs published in the past 3 years (n = 450 reports). The sample was stratified by the US Department of Agriculture's Rural-Urban Continuum codes to balance hospital representation from metro and nonmetro areas.

RESULTS

A series of dependent t tests revealed that these hospitals' reports represented a significantly more female, White, college-educated, and older population than the service area. In addition, only 3.12% of hospitals collected primary youth data. Finally, results also found that survey recruitment was not inclusive of individuals who did not have Internet access, could not read, or did not speak English fluently.

Community Coalitions' Perspectives on Engaging with Hospitals in Ohio to Address the Opioid Crisis

Community coalitions have been leading the multisector response to the opioid epidemic in the Unites States. However, with the medicalization of opioid use disorder and changing health care policies, hospitals have moved to the forefront, becoming more active in collaborating with community coalitions. Little is currently known about how community coalitions view and approach collaborating with hospitals despite its importance for understanding and advancing interorganizational approaches to combating the opioid epidemic. Using data from semistructured interviews (n = 119) conducted from November 2019 to January 2020 as part of the HEALing Communities Study (ClinicalTrials.gov: NCT04111939), the authors examined how community coalition members perceive hospital collaborations and explored the opportunities and challenges of these partnerships. They characterized 3 emergent themes: coalition approaches to collaborating with hospitals, barriers to collaboration, and opportunities for sustainable relationships. This new evidence highlights the value that coalitions place on hospital collaborations, as well as mechanisms that may help support ongoing partnerships.

Overview of the Most Commonly Identified Public Health Needs and Strategies in a Nationally Representative Sample of Nonprofit Hospitals

Nonprofit hospitals have been required to conduct Community Health Needs Assessments and develop implementation strategies for almost a decade, yet little is known about this process on the national level. Using a nationally representative dataset of 2019 to 2021 nonprofit hospital community benefit reports, we assessed patterns in hospital identification of community health needs and investments in corresponding programs. The five most common needs identified by hospitals were mental health (identified by 87% of hospitals), substance use (76%), access (73%), social determinants of health (69%), and chronic disease (67%). The five most common needs addressed were: mental health (87%), access (81%), substance use (77%), chronic disease (72%), and obesity (71%). Institutional and community-level factors were associated with whether hospitals identified and addressed health needs. Hospitals often addressed needs that they did not identify, particularly related to the provision of medical services—which has important implications for population health improvement.

Obamacare: A bibliometric perspective

Obamacare is the colloquial name given to the Affordable Care Act (ACA) signed into law by President Obama in the USA, which ultimately aims to provide universal access to health care services for US citizens. The aim of this paper is to provide an overview of the political-legal, economic, social, management (or administrative), and medical (or health) repercussions of this law, using a bibliometric methodology as a basis. In addition, the main contributors to research on ACA issues have been identified in terms of authors, organizations, journals, and countries. The downward trend in scientific production on this law has been noted, and it has been concluded that a balance has not yet been reached between the coexistence of private and public health care that guarantees broad social coverage without economic or other types of barriers. The law requires political consensus to be implemented in a definitive and global manner for the whole of the United States.

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.

Hospital Service Offerings Still Differ Substantially By Ownership Type

Nonprofit, for-profit, and government hospitals are all more likely to offer services when they are relatively profitable than when they are relatively unprofitable. However, for-profit hospitals are considerably more likely than others to provide services based on profitability. After hospital and market characteristics are adjusted for, nonprofit hospitals offer relatively unprofitable services more than for-profit hospitals and less than government hospitals. Profitable services typically exhibit the opposite pattern. For-profit hospitals are also more likely to adopt or discontinue services consistent with changes in service profitability than are nonprofits, which in turn are more likely to do so than government hospitals. These results are similar to those we found before passage of the Affordable Care Act, when many more patients were uninsured. Policy makers and researchers tend to focus on whether nonprofit hospitals provide sufficient free care to justify tax benefits, thereby overlooking the significance of ownership for service provision, which likely has critical health and spending consequences.

Assessing Concordance Across Nonprofit Hospitals' Public Reporting on Housing as a Community Health Need in the Era of the Affordable Care Act

Although the Affordable Care Act requires nonprofit hospital organizations to report how they identify and invest in community health needs, the utility of mandated reporting documents for tracking investments in the social determinants of health has been questioned. Using public reporting documents and focusing on housing as a social determinant of health, we describe how nonprofit hospital organizations in 5 communities with the highest rates of homelessness document needs and investments related to housing on their Community Health Needs Assessments, Implementation Strategies, and Schedule H (990H) tax forms. Of 47 organizations, 55% identified housing as a health need, 36% described housing-related implementation strategies, and 26% reported relevant 990H spending. Overall concordance among identified needs, strategies, and spending was low, with only 15% of organizations addressing housing across all 3 documents. Regulatory reform could help promote accountability and transparency in organizations' efforts to address housing and other health-related social needs.

Institutional factors associated with hospital partnerships for population health: A pooled cross-sectional analysis

BACKGROUND

Hospitals are increasingly engaging in partnerships to address population health in response to national policies, such as value-based payment models. However, little is known about how institutional factors influence hospital partnerships for population health.

PURPOSE

Guided by institutional theory, we examine the association between institutional pressures (coercive, normative, and mimetic isomorphism) and hospital partnerships for population health.

METHODOLOGY

A pooled cross-sectional analysis used an unbalanced panel of 10,777 hospital-year observations representing respondents to a supplemental question of the American Hospital Association's annual survey (2015-2017). The analysis included descriptive and bivariate statistics, and regression models that adjusted for repeated observations to examine the relationship between key independent variables and partnerships over time.

FINDINGS

In regression analyses, we found the most support for measures of coercive (e.g., regulatory factors) isomorphism, with nonprofit status, participation in accountable care organizations, and acceptance of bundled payments, all being consistently and significantly associated with partnerships across all organization types. Modest increases were observed from 2015 to 2017 for hospital partnerships with public health organizations (+2.8% points, p < .001), governmental organizations (+2.0% points, p = .009), schools (+4.1% points, p < .001), and businesses (+2.2% points, p = .007).

PRACTICE IMPLICATIONS

Our results suggest that institutional factors, particularly those related to regulatory policies and programs, may influence hospital partnerships to support population health. Findings from this study can assist hospital leaders in assessing the factors that can support or impede the creation of partnerships to support their population health efforts.

Financial Profit in Medicine: A Position Paper From the American College of Physicians

The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics. In this position paper, ACP considers the effect of mergers, integration, private equity investment, nonprofit hospital requirements, and conversions from nonprofit to for-profit status on patients, physicians, and the health care system.