The Conversation About Community Health & Social Determinants Has Evolved. How We Count Hospitals’ Contributions Should Follow Suit

Here’s a list of terms that were not a significant part of the health care dialogue in 2009: social determinants of health, community health needs assessment, population health management, and health equity. U.S.-based internet searches for these terms markedly increased between April 2009 and April 2019 (see Figure 1), no doubt in part due to the passage of the Affordable Care Act, which sparked interest — and action — across all four domains in the intervening decade.

Figure 1: Google Search Trends, United States, 4/2009 – 4/2019

April 2009 also marked the first time not-for-profit hospitals were required to report their community benefit spending to the Internal Revenue Service (IRS) on the newly created Schedule H. As defined in 2009, community benefit is a composite measure consisting of dollars related to “financial assistance and means-tested government programs” (e.g., charity care or Medicaid) plus “other benefits” including cash and in-kind contributions, dollars spent on community health improvement activities, and, for teaching hospitals, health professions education and research dollars.

Mostly though, politicians, reporters, and researchers focus on charity care and subsidized health services as the main indicators of a hospital’s community commitment. The problem is, providing free or subsidized health care to patients has a limited impact on community health as we understand the term in 2019.

The time has come for the tax form to match the desired function.

Four Steps to Get Us There

There is no denying that not-for-profit hospitals and health systems are committed to the patients and communities they serve. There is also no denying that, as currently structured, community benefit reporting is an imprecise process that incentivizes relatively accurate reporting of cash losses and disincentivizes (or makes confusing) reporting on interventions and partnerships that are more likely to have an effect at the community level. Those activities, arbitrarily called “community building” by the IRS, are relegated to the second page of Schedule H — a page rarely viewed that contains information rarely reported to the public.

The health care community, in partnership with public health experts, scientists, policymakers, patients, and community members, should reconsider what might be the most effective and appropriate ways for a hospital to be the best partner it can be in the multisector collaborative necessary to impact community health and health inequities and figure out how to operationalize that on a tax form. To do this, we must:

1.      Pay careful attention to language and definitions,

2.      Turn to the evidence base for guidance,

3.      Consider how hospital policies can contribute to community well-being, and

4.      Not shy away from fundamental causes while being realistic about hospitals can do.

What Are We Actually Talking About?

How many times have you heard a health care professional say they treated a patient suffering from health disparities? I’ve heard it dozens of times. The problem is, a person doesn’t suffer from disparities (or inequities, as I prefer to call them), populations do. By definition, health inequities are measurable, systematic, avoidable, and unjust differences in health between groups of people, largely due to differences in social advantage. Inequities are population health phenomena.

But what does population health mean? To health care providers and hospital administrators, we’re likely talking about capitation and value-based purchasing arrangements for a defined group of patients. For public heath partners, we’re talking about total population health related to health outcomes of entire communities, neighborhoods, and states. At what level, then, do we think hospitals, via their community benefit and related community health needs assessment (CHNA) activities, are best able to have an impact?

The word community, though, is also problematic. Mergers and acquisitions cobble together (sometimes) contiguous areas that are certainly not uniform communities to the residents living there. Different neighborhoods will require different interventions. Rural providers’ community might span an entire state. And specialty hospitals might treat people from all over the world. How do foreign patients factor into local community health improvement activities to address the social determinants of health (SDOH)?

But wait! As others have written, hospitals have begun to move “upstream” to supposedly address community-level SDOH, but they’ve actually come full stop “midstream” to address patient social risk. That is, while investing in free or subsidized housing units for homeless patients is important and effective work to increase the likelihood that those homeless patients achieve better health, it does nothing to address the underlying causes of homelessness in the community (i.e., system-level social determinants related to economics, gentrification, or education).

Where should hospitals intervene? Right-sizing our language is the first step in right-sizing community benefit expectations.

Let Research Light the Way

“Eighty percent of health has nothing to do with health care,” is a maxim, grounded in County Health Ranking methodologies and science. That means that at the very least the health care system “owns” a full 20% of health. That 20% consists of, according the Rankings’ framework, health care quality and access. Thus, to be that best partner in the multisector collaborative necessary to address community health and health equity, hospitals should at a minimum incorporate addressing patient social risk into their quality and access initiatives.

Community benefit as currently reported tells us little to nothing about the ways in which not-for-profit hospitals screen for, diagnose, and refer for social risk. Nor does it offer insight about how partnerships with referral sites are structured, funded, maintained, or evaluated. It also doesn’t require that the interventions developed in response to the triennial CHNA relate to community benefit spending, missing an opportunity to show how addressing patient social risk can simultaneously address prioritized community health needs.

Significant scientific evidence exists about the kinds of patient social risk interventions that are likely to improve patient population health outcomes. Integrated pest management and mold abatement for asthmatic patients living in substandard housing. Legal interventions to ensure patients have access to education, supplemental income, and other benefits to which they are entitled. Grocery delivery services for food insecure patients. Current community benefit reporting doesn’t readily allow for transparency about whether hospitals are selecting evidence-based interventions and then adapting them for local patient and community asset characteristics, funding them, and evaluating the benefits.  

Don’t Underestimate the Power of Policies

Another term that achieved entered into the health care dialogue in the decade between 2009 and 2019 is “Anchor Institution.” While most hospitals and health systems are anchors by default — they are large and aren’t going anywhere — very few are walking the anchor mission walk, characterized by adopting a community economic development focus across various kinds of institutional policies. Does your institution’s procurement policy prioritize local vendors? Does the HR department have and meet targets for hiring locally? Does the institution include local investments in small businesses and start-ups as a part of its investment portfolio?

Policies like these that direct hospital investments and spending into local coffers certainly do more to improve community health than does accounting for Medicaid shortfall dollars.

Policies related to quality improvement (QI) activities might also be important to consider and would allow for a formal focus on issues of health care equity — another aspect of patient population health nearly wholly owned by the health care system. Too often QI interventions are developed with a “rising tide lifting all boats” mentality and without first assessing whether there are inequities in health care processes or outcomes that need to be explicitly addressed. Whether or not not-for-profit hospitals are stratifying their patient data by social risk factors to understand where inequities exist is at least as valuable a measure of “patient / community benefit” as is the dollar amounts spent on free care. How many quality improvement-related interventions were developed in response to those uncovered inequities — and how effective they were in closing those gaps — might be an even better metric.

The Elephant Upstream

Focusing on the 20% doesn’t absolve not-for-profit hospitals from working to address fundamental causes of poor community health and health inequities. Rather, it forces us to think through how a hospital can be that best partner, since it is absolutely not the health care system’s job to solve an issue like racism or poverty on its own.

We could start, of course, with how a hospital encourages equity and justice among its own employees given that hospitals are major employers in their local communities. Pay equity, living wage policies, and addressing implicit and explicit biases have significant community benefit relevance. Ensuring patient and community representation in governance structures is another important strategy to integrate the local community more fully into health care institutions. Stronger, more trusting relationships between the hospital and its community add benefit bidirectionally. Convening and building local coalitions and serving as “backbone institutions” for collective impact strategies all play to hospitals’ strengths, and are already recognized as community building activities.

Lastly, the health care system brings a powerful advocacy voice to political tables at all levels — local, state, and federal. Lending that voice loudly and clearly to change policies and structures that give rise to poor community health and health inequities is another way to benefit the community and populations served by the hospital.

Schedule H2

How would we operationalize these activities into reportable metrics? What might a Schedule H that reflected the 2019 community health conversation look like?

First, for continuities’ sake, we should not wholly abandon reporting on financial assistance and means-tested government programs. Providing health care to those who cannot afford it is an essential role of the health care safety net. We could, perhaps, collapse those dollars into one row to minimize its prominence.

Insofar as additions go, the thoughts above certainly point toward some potential domains:

1.      Investments in processes related to social risk referral across CHNA-prioritized areas like transportation, housing, and food access. This could include the development of technology, hiring of dedicated staff, financial support of local community-based referral partners, etc.

2.      Health care equity-focused investments in identifying and eliminating gaps in health care processes and outcomes, including equity-focused quality improvement data systems, salaries of dedicated “health care equity FTEs”, investments in staff training and education on these issues, investments in intervention development and deployment, and reporting of results/trends over time.

3.      Investments in local businesses, the presence or absence of “hire local” and “procure local” policies, and the dollar amounts of those local investments.

4.      Investments in support of the entire CHNA process — from assessment to intervention development to evaluation.

5.      Investments related to moving towards pay equity and local living wages for all hospital staff.

6.      Investments in local coalition building and convening, including the presence of community members on important governance bodies.

7.      Investments in advocacy activities related to addressing health-harming policies at the local and state levels.

Ultimately, since the desired work is inherently collaborative and community-engaged, so too should any tax form redesign process be. But by getting the language, activities, and measures aligned, there is a real possibility that we can provide clarity and guidance for hospitals about being that best partner, appease critics dubious of the community value add of tax breaks, increase transparency so the public really understands what not-for-profit hospitals are up to, and, most importantly, contribute maximally to the health and well-being of patients and communities.