Community Health Improvement and Equity: From Minimum Standards to a Quality Improvement Approach

By: Kevin Barnett, DrPH, MCP, Co-Director, CACHE and Senior Investigator, Public Health Institute

Image credit: Public Health Institute

Image credit: Public Health Institute

Welcome to the opening blog for the Center to Advance Community Health and Equity. CACHE was established through a grant from the Robert Wood Johnson Foundation for all who share our commitment to align and focus community health improvement services and activities where health inequities are concentrated.  Consistent with the CACHE acronym, our intent is to serve as a “treasure trove” of tools and resources to support generative dialogue that advances community health practices.

At the core of those tools is Community Benefit Insight (CBI), a searchable platform that provides user-friendly access to the annual data reported by tax-exempt hospitals on their IRS 990 Schedule H, outlining community benefit expenditures, financial assistance policies, and other related information.  CBI was developed by a team at RTI International, and they regularly update and refine the platform with input from the CACHE team at the Public Health Institute.  CBI serves as a resource for researchers across the country and a powerful tool for diverse stakeholders to engage hospitals and others in their communities to work together and improve community health practices. 

Community and population health have become high profile concerns, driven in part by the movement towards “value-based” reimbursement in the health care arena and the assumption of financial risk among providers and payers to keep people healthy and out of acute care facilities.  It is also driven by growing economic inequities and an increasing awareness that an array of factors we now refer to as the social determinants of health (SDH) have a profound impact upon health and well-being.  Where we live, including the quality and safety of our homes, neighborhoods, and schools, as well as our access to healthy foods, basic goods and services, and jobs with livable wages are becoming shared societal concerns. 

Tax-exempt hospitals are faced with the imperative to invest in data systems and care redesign in a time of declining revenues and increasing penalties for readmissions and poorly managed care. At the same time, they are expected to work with diverse stakeholders to improve health in proximal low-income communities.  Scrutiny has once again escalated at the federal level as Senator Grassley recently issued a February 25th letter questioning tax-exempt hospital practices and the oversight responsibilities of the IRS.

Truth be told, what tax-exempt hospitals report to the federal government on their form 990 Schedule H provides only a partial picture of their charitable contributions.  Aside from the fact that they are not permitted to include community building expenditures, services and activities that reside squarely in the realm of the SDH, there are a broad array of other charitable contributions made by tax-exempt hospitals, ranging from policies that require purchasing from local vendors to investments in affordable housing and healthy food financing. 

A recent article in Modern Healthcare appropriately notes that the 990H doesn’t tell the whole story.  It is also important to note that the bar set by the IRS is quite low, which is one of the reasons there continues to be a drumbeat of questions from legislators as to whether current regulations are sufficiently targeted to best assure the desired organizational behavior.  In the Modern Healthcare article, the IRS is quoted as having cited 388 hospitals out of 1193 analyzed for issues with CHNAs, financial assistance policies or billing and collection practices.  This is consistent with a minimal expectation standard driven by the maxim “did you follow the letter of the law?” not a standard that encourages a quality improvement approach to community benefit. 

An essential question not addressed in the article is what level and form of transparency is appropriate.  It is difficult, if not impossible, to set performance standards at the federal level for approximately 3000 highly diverse institutions operating in equally diverse community circumstances.  You can, however, establish public expectations at the local and regional level that provide the basis for an independent evaluation of relative commitment to optimal stewardship.  This should include an assessment of institutional commitment to focus a substantial proportion of services and activities in implementation strategies (not just CHNAs) in specific communities where health inequities are concentrated.  It should be noted that the IRS regulations include a requirement for hospitals to include “an evaluation of the impact of any actions that were taken to address the significant health needs identified in the immediately preceding CHNA.” It is unclear what is meant by this language, as no further guidance is provided in the instructions. 

A local/regional transparency standard established by diverse stakeholders, including hospitals, municipalities, public health and social service agencies, community-based organizations, community members, and large local employers would challenge all to align and focus complementary assets in communities where health inequities are concentrated, and establish metrics that validate progress toward aggregate level outcomes.  Metrics should include process measures that document changes in practices (e.g., resource sharing, changing hours of operations, sharing space, leveraging expertise; institutional policies (e.g., establishing expectations that bring to bear expertise, influence, and sustained commitments); outputs (e.g., increased affordable housing, grocery stores and healthy food corner stores, and child care centers); and outcomes (e.g., reduced preventable utilization, readmissions, reduced absenteeism, and increased tax revenues). 

The imperative for greater transparency and for shared ownership to build health and well-being in our communities is before us, and there are an increasing array of tools and resources available to align and focus our efforts in communities where health inequities are concentrated.  Our team at CACHE looks forward to working with hospitals and diverse stakeholders in communities across the country to advance practices that improve health and well-being and reduce health inequities in our communities in the coming years. 

Stay tuned…