Ahead of the Curve in Redefining Community Benefits

By: Paul Dworkin, MD

In this age of health care reform, it is crucial for all nonprofit hospitals to take a fresh look at how they fulfill federal requirements for documenting how they benefit their communities to secure tax exempt status. It’s something we’ve already been doing for quite a while here at the Connecticut Children’s Office for Community Child Health.

Here’s why a new approach is needed.

In the past, nonprofit hospitals have primarily, although not exclusively, defined community benefit by the financial assistance they provide to uninsured or underinsured patients when payments are less than the cost of care. Hospitals also report “community health improvement” expenditures that support programs that improve community health but do not generate patient revenues. In general, the latter represent only a small percentage of overall community benefit spending. For example, in 2011, hospitals allocated less than $2.7 billion out of nearly $62.5 billion in community benefit spending to such community health improvement activities.

Now, the reduction of uninsured Americans as a result of the Affordable Care Act and the legislation’s focus on community health planning has encouraged hospitals to consider how to expand the concept of community benefit to build a healthier society.

Here at the Office, we have embraced a broader definition of community benefit that includes community-building activities. Indeed, even a cursory review of our community-oriented programs reveals the extent to which they address such social determinants of health as housing (e.g., Connecticut Children’s Healthy Homes), food and nutrition (e.g., Hartford Childhood Wellness Alliance), community safety (e.g., Injury Prevention Center), and early childhood development (e.g., Help Me Grow® National Center).

The Connecticut Children’s Community Benefit Report now includes an annual summary of activities from the Office and its programs. Furthermore, the Office’s focus on system building that engages the myriad of sectors so crucial to family well-being and promoting children’s healthy development also reinforces the integrated notion of community building and community health improvement. Consider the diversity of sectors captured as petals in our ubiquitous “flower diagram” for system building. In addition to the “usual suspects” of child health, early care and education, and family support, we also call out such critical factors as food and nutrition, housing, economic development, workforce development and employment, neighborhood health and safety, arts and culture, and transportation.

A recent blog appearing on the website of the important and prestigious publication, the journal Health Affairs, takes a closer look at the issue of how and why nonprofit hospitals may be embracing new opportunities in documenting their community benefit.

Sara Rosenbaum and Bechara Choucair, MD, co-authored the blog. Rosenbaum is a prominent and influential healthy policy expert and advocate who is best known for her work on the expansion of Medicaid, the expansion of community health centers, patients’ rights in managed care, civil rights and health care, and national health reform. Dr. Choucair is senior vice president for safety net transformation and community benefit for Trinity Health. His leadership of Trinity Health’s strategic focus to build a people-centered health system that improves the health of populations and impacts the community-based social determinants of health is of particular interest given the system’s recent acquisition of Connecticut’s Saint Francis Hospital and Medical Center and Johnson Memorial Medical Center.

The blog goes on to discuss the nuanced issue of whether “community building” activities should fall within the legal definition of “community benefit.” At present, such expenditures as physical improvements and housing, economic development, community support, and environmental improvements are not considered community benefits, despite research confirming their positive influence on population health. The authors describe the impact of Trinity Health’s Transforming Communities initiative on social determinants of health in an effort to “bring community-building activities squarely into the community health improvement orbit.”

Regardless of the likelihood and feasibility of an official change in community benefit policy at the federal level, we are hopeful that the community building efforts of health care institutions and their systems will be increasingly recognized as contributing to community health benefits. The determinants of health demand that we be mindful of the importance of this wide array of contributing factors.

In the interim, we will continue to view our community benefits through both such traditional measures as uncompensated care, as well as the broad impact of our community-oriented programs and services. Our commitment to making the children of Connecticut the healthiest in the nation deserves no less.

Paul Dworkin, MD, is the executive vice president for community child health at Connecticut Children’s, the director of the Connecticut Children’s Office for Community Child Health and the founding director of the Help Me Grow® National Center. Dr. Dworkin is also a professor of pediatrics at the UConn School of Medicine.  Learn more »

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