Insights for Change

Ahead of the Curve in Redefining Community Benefits

By: Paul H. Dworkin, MD

In this age of health care reform, it is encouraging to see more hospitals and health systems redefine the way in which they fulfill their community benefit obligations under the Affordable Care Act (ACA). It is also encouraging to see states begin to reconsider their approaches.

At Connecticut Children’s, we have long embraced a broader definition of community benefit than is required by the ACA. Through our community-focused work at Connecticut Children’s Office for Community Child Health (the Office), we are proud to be ahead of the curve in this important area.

Building a Healthier Society

In order to maintain tax-exempt status, the ACA requires non-profit hospitals to identify community needs and report annually on their progress toward addressing those needs. Prior to the ACA, nonprofit hospitals primarily, although not exclusively, defined community benefit by the financial assistance they provide to uninsured or underinsured patients when reimbursements do not cover the full 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, back in 2011, hospitals allocated less than $2.7 billion out of nearly $62.5 billion in community benefit spending to community health improvement activities.

Now, the continued reduction of uninsured Americans because of the ACA and the legislation’s focus on community health planning encourages hospitals to consider how to expand the concept of community benefit to build a healthier society.

Here at the Office, our broader definition of community benefit includes traditional measures as well as our community building activities, which fall outside the federal reporting requirements. 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., Kohl’s Start Childhood Off Right ), community safety (e.g., Connecticut Children’s Injury Prevention Center), and early childhood development (e.g., Help Me Grow National Center).

Connecticut Children’s Community Benefit Report includes an annual summary of activities from the Office and its programs. Furthermore, the Office’s focus on cross-sector system building 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 sectors that are critical to strengthening families to promote children’s optimal healthy development as food and nutrition, housing, economic development, workforce development and employment, neighborhood health and safety, arts and culture, and transportation.

The Need for a New Approach

The conversation about the need for hospitals and health systems to expand their community benefit focus is not new, yet a good number continue to struggle to embrace substantive change. As that conversation continues, the importance of this reporting is encouraging states to reconsider their approaches. For example, Connecticut is considering transferring its community benefit reporting requirements from the Office of Healthcare Advocate to the Office of Health Strategy and increasing the focus on how community benefits address the healthcare needs of the population.

A blog published by the prestigious journal Health Affairs takes a closer look at the issue of how and why nonprofit hospitals should embrace new opportunities to document their community benefit.

The blog, co-authored by Sara Rosenbaum and Bechara Choucair, MD, discusses 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.”

The Future of Community Benefits

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, in which social and environmental factors outweigh the impact of medical care, demand that we recognize the importance of this wide array of contributing factors.

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

Read more of our Insights for Change blogs.

Paul H. Dworkin, MD, is executive vice president for community child health at Connecticut Children’s, director of the Connecticut Children’s Office for Community Child Health and 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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