Tracking hospital community investments
Progress has been made, but there’s still work to do
IN FEBRUARY, ATTORNEY GENERAL MAURA HEALEY released her office’s revised community benefit guidelines for hospitals and for HMOs—with scant media attention. This surprised the two of us a bit, as many a health policy discussion in recent years centered on issues of greater hospital accountability for investing resources to advance community health status, as well as an expectation that hospitals make a more deliberate pivot to dedicate resources and efforts to address social determinants. Both issues, which were advanced in this year’s revised guidelines, had last been updated in 2009.
For the two of us, authors of a 2016 report entitled “Hospitals Investing in Health,” published by Community Catalyst and funded by the Blue Cross Blue Shield of Massachusetts Foundation, which summarized the state of hospital community benefit issues in the Commonwealth, we are especially pleased with the real progress that has been made with these guidelines to help move the field to better address concerns that we had raised in our 2016 analysis.
We think the revised guidelines keeps Massachusetts in the forefront of hospital community benefits thinking nationally; and although our state’s guidelines are voluntary, the communal ethic that exists across our state’s providers and local insurers tends to make our health care industry treat them with a fair amount of seriousness. While our state scheme is somewhat novel in that there are community benefit guidelines for insurers as well (noted from their origins as “HMO guidelines”), our focus here is on the hospital set.
While we suggest that the reader may want to read our 2016 report for its detail about why previous guidelines have led to submissions by hospitals to the attorney general’s office that have been lacking in some important ways, here is our list of concerns and opportunities for real improvement that we noted in the 2016 report:
- Lack of a strategic approach in community benefit efforts: For the most part, we found that hospitals generally submit unfocused narrative reports with little evidence of strategic thinking about what they are really trying to accomplish in a measurable way tied to health status improvement. Also, a hospital could report multiple program activities related to a particular health improvement goal, but there is usually no mechanism to determine which, if any, of these efforts are viewed as strategic priorities.
- No serious use of a “community benefits plan.” In addition to submitting unfocused narrative summaries of some of their activities, most hospitals do not send the attorney general the plans (called implementation strategy by the IRS regulations) that they submit to the federal government as part of their annual nonprofit tax filings. Though the Affordable Care Act now mandates the creation of these implementation strategies—it has not been clear to us that hospitals give much serious attention to what these documents seem to promise in terms of focus and resource commitments for their community benefit efforts.
- Lack of coordination among hospitals and duplication of efforts: Hospitals may be carrying out community benefit programs in the same geographic areas as their competitors—but there is no coordination of efforts or attempts to avoid being redundant.
- Lack of measurement of community benefit efforts: Hospitals report activities and sometimes the number of participants, but often lacking are clear measurable health status related goals and objectives for accomplishment tied to community benefit efforts.
- Lack of transparency in how money was spent: While hospitals submit a total dollar resource commitment number for community benefit, there is almost never any way to discern how much is being spent on any particular community benefit activity.
- A wide range of hospital commitment and investment: Even if we put aside previous guidelines’ suggested range of overall community benefit commitments of at least 3 percent of total patient expense—a target not achieved by the majority of hospitals–even more disappointing to us was the specific lack of a resource commitment to community health improvement efforts at a good number of institutions.
- Community engagement often missing, or incomplete: Except for some community members being asked to participate in the qualitative parts of community health needs assessments—sometimes in a limited and scatter shot sort of way, at most hospitals there was no evidence that there was regular community engagement in the planning, evaluation, and reporting phases of community benefit efforts. Hospitals often list multiple community organizations as being recipients of their community benefit outreach—but there is no way to ascertain the specific nature or extent of the engagement from one organization to another; or whether there is any outreach beyond the needs assessment phase.
- Disconnect between the state public health department’s required community engagement related to determination of need and the attorney general’s community benefit process: At many hospitals that have taken on capital projects and the required community health improvement efforts tied to their determination of need obligations, these activities and community engagement efforts sometimes operate in a separate track from the annual community benefit effort that are reported on to the attorney general.
- Hospital accountability for taking on social determinant factors was often quite minimal: most community benefit efforts were tied to medical care activities, and while some address inequity issues for vulnerable populations—very few were focused on social determinant factors (e.g. affordable housing, food security, or transportation issues). There was little or no investment in long term sustainable programs designed to build community capacity or to improve health outcomes and/or reduce disparities.
Our report concluded with a set of policy recommendations—the thrust of which was directed at various suggestions for better aligning the overall regulatory and accountability framework between state and federal governments, increasing transparency of hospital planning and related activities, and putting forward some ideas for improving hospital engagement with community groups.
What has resulted since October 2016?
Before we turn to summarizing the attorney general’s important accomplishments with its revised guidelines, it is important to note how the Department of Public Health has been a thought leader for state government in many ways in the community health improvement realm–effecting both its own regulations tied to the determination of need process as well as the content of the attorney general’s community benefit guidelines. The revised 2017 Department of Public Health regulations overhauled a system that was not in “synch” with many of the structural changes in health care delivery.
Department of Public Health Commissioner Monica Bharel described the revised determination of need regulations as an effort to meaningfully infuse public health and population health principles within this longstanding health care regulation tied to hospital capital projects; with a hope that the regulation promoted both successful cost containment while advancing efforts to tackle social determinants of health. Along with an enhanced set of expectations tied to the required community health improvement process that accompanies capital projects, the Department of Public Health regulations and sub-regulatory guidelines, in addition to maintaining its practice of asking hospitals to dedicate 5 percent of total project level spending for community health improvement, also require the following:
- Significant and continuous community engagement in all phases of the community health improvement process. This includes both identifying the general priority areas for community health improvement efforts, as well as involvement in helping to identify the specific activities that will be carried out.The focus for community health improvement priorities include the need to advance statewide priorities for the majority of dollars spent—with a real push toward social determinant-related investments in six areas and/or work on four focused issues of concern identified by the secretary of health and human services.
- There is also a payment of about 15 percent of the community health improvement total dollars into a statewide fund where the monies will ultimately be dedicated to activities tied to these 10 areas of focus in parts of the state where there is no hospital presence. Given that most hospital expansion occurred within the greater Boston area, this is an important development which especially helps bring resources to less populated areas of the state.
- Community engagement tied to these community health improvement efforts include both a self-assessment by the hospitals of their progress in improving the extant and level of community engagement, as well as an assessment that is made by the community members that participate in aspects of the community health improvement process on the hospital’s outreach and engagement efforts.
Attorney General Process
Last April, Attorney General Healey convened an advisory task force comprised of hospital, community, and public health leaders to discuss updates to the guidelines, which had last been revised in 2009. Healey noted that Massachusetts health care institutions report that they provide hundreds of millions of dollars annually to address community health issues and charged the committee with “crafting solutions for communities.” After a series of task force meetings and some public hearings, revised guidelines were promulgated in early February. Unlike the past, this new set of guidelines were crafted to align both with the Internal Revenue Service as well as Department of Public Health regulations—all in all a much more holistic approach to community benefit oversight. The new set:
- Places a more definitive emphasis on community benefit planning and prospective transparency of what the hospital intends to do in the upcoming year through annual submission of its yearly Implementation strategy. Requirements by the attorney general’s office also mandate that this plan contain measurable objectives for the topical areas identified.
- Mandates community engagement at all steps of the community benefits process—not just at the community health needs assessment level. Community engagement is noted as an integral part of the community benefit process at all levels–from assessment, through planning and evaluation. The guidelines also require hospitals to host an annual meeting with community members to report on the overall progress of their community benefit efforts.
- Specifies improved reporting tied to expenditures. Hospitals will be required to distinguish medical care services from one’s that that are public health or programs designed to address upstream social determinants of health. They are also expected to also report their activities tied to the identified health need it is responding to. Finally, for the first time, there will be an ability for report readers to see which of the community benefit dollars were spent internally versus externally to the hospital organization.
- Promotes a greater emphasis on regional planning and sharing of best practices among hospitals. Hospitals will be required to report whether they engaged in regional planning, and if not, why. Such joint efforts are encouraged under the new guidelines to reduce duplication and maximize investment. Already a consortium of western Massachusetts hospitals engage in a regional planning process with key community partners and recently the Conference of Boston Teaching Hospitals has begun a common community health needs assessment process.
- Pushes hospitals to encourage more social determinant-related efforts in a more consistent way, following Department of Public Health and its public health priorities. The new guidelines not only utilize the Department of Public Health framework for the specific social determinants of health and campaign areas, but they adopt a recognition of the role of structural racism as an important contributor to health inequities and strongly suggest that this is an important issue to address through hospital community benefit efforts.
- Encourages the sharing of best practices among hospitals. Millions of dollars are spent every year but there has been little discussion of what works and why. The guidelines suggest that attorney general’s office plans to work collaboratively with the Department of Public Health and possibly other governmental agencies to sponsor some future meetings for the sharing of best practices and advance other ideas aimed at optimizing community health improvement.
- Hospitals will be required to self-assess the extent and success of their community engagement at least every three years following the same framework established by the Department of Public Health last year. Community groups will be able to provide their own assessment of the hospital’s approach via a feedback form that is shared with both the hospital and the attorney general.
- These guidelines represent a significant improvement over the current set. Community benefits are a two-way process: hospitals and communities will need to engage in an open and dynamic process that should enable both the hospital and community organizations to work together to meet the needs of their respective communities. As hospitals often have much greater resources than many community organizations—they should be an important source of funds for advancing such a common purpose.
- More detailed program/activity financial reporting: In the face of hospital-expressed concerns, attorney general did not require that hospitals provide activity/program level reporting. Instead, hospital activities are grouped together under three categories of activity spanning from those most connected to clinical care to those that are more “public health” in their scope; they are also tied to the category of health need addressed (e.g. chronic disease, substance abuse, mental health, etc). While this provides greater data than before, communities may still be in the dark about the extent of resources that hospitals are choosing to dedicate for specific programs or activities—and so it may not be clear as to how resource commitments match up against stated priorities that are articulated in a hospital’s implementation strategy.
- Scheme for community benefit credit by accounting for affordable housing investments that have less than market rate of returns: One of the areas for social determinant investments which have been shown to have particular importance for those who are chronically mentally ill-but also for those who have chronic conditions which can often be exacerbated by poor housing conditions, is the need for quality, affordable housing. The Boston metro area is in particular need of such affordable housing. One idea was to allow hospitals to obtain “community benefits credits” for making equity investments in housing where the amount credited would be the difference in some projected market rate of return for their investable assets as compared to what they in fact earned from making an affordable housing investment. While no such provision was added to the guidelines, the guidelines do allow for a written supplement where details about projects like affordable housing investments can be described in a narrative form.
- More robust process for community commentary on hospital efforts: Historically, the attorney general has maintained a process for community groups to offer commentary about a hospital’s community benefit efforts. The new guidelines essentially maintain the prior, somewhat mechanical process steps where a group wanting to offer public commentary needs to notify and then meet with the community benefit staff of the hospital it wants to offer commentary about. While the new feedback form should support more hospital learning about community perspectives from those who complete it; we do not think it is a substitute for community commentary about a hospital’s community benefit efforts. We remain worried that the required process steps could chill useful commentary from coming forward. After all no commentary about a hospital’s community benefit report or efforts has ever found its way on to the attorney general’s website to date.
- More clarity around ongoing attorney general auditing and accountability scheme after receiving annual submissions: Over the years, the attorney general has provided a more limited audit in reviewing the submitted hospital reports—primarily for factual errors or inconsistencies. From our review, a good number of submitted hospital reports have lacked sufficient detail to convey a sense of completeness; or contain claims for community benefit activities which stretch the imagination for coherency and having a relationship to improving health status. Some hospitals provide minimal financial investment in community based programs. While acknowledging that the guidelines remain, as they have always been, technically voluntary, we believe the communal ethic among the providers would be responsive (both individually and collectively) to any attorney general effort to publicly point to shortcomings in hospital efforts, reports, and plans that come to the attention of the attorney general on an annual basis.
Following the February promulgation of the guidelines, there will be a phase-in period. The first official year for full adoption will be FY2019 which begins next October 1.
In the intervening year, it is our hope that the attorney general ‘s staff will hold training sessions for hospitals, community benefit advisory groups and, community organizations. In addition, we know that in prior guideline revision efforts, the Massachusetts Health and Hospital Association has made sustained efforts to bring its members up-to-date on the guideline changes and their implications for process changes. We think that will be useful to the field. As part of a group of community advocates, we too plan educational efforts for community groups and individuals. The new guidelines present new opportunities for community organizations to advocate for greater hospital investment in their communities and it will be up to them to become knowledgeable so they can effectively advocate for their communities.In addition, we hope, with local foundation sponsorship to try something a bit new—which is to specifically outreach to those people who are or will be part of hospital community benefit advisory groups. Our aim is to help them not only understand the aim and specifics of the revised guidelines, but also educate them to take on a more proactive and assertive role as they work collaboratively with hospital community benefit staff on what we hope will be truly robust community benefit efforts which clearly lean toward inclusion of social determinant related activities.
Paul Hattis is an associate professor at Tufts Medical School and Enid Eckstein is active in community engagement, development, and healthcare transformation,