Kevin Barnett, Dr.P.H., M.C.P., a senior investigator with the Public Health Institute, an Oakland, Calif.–based nonprofit focused on strengthening the nation’s public health system, has spent the last two decades researching the ways nonprofit hospitals meet their charitable obligations. Part of this work includes looking at how hospitals spend their community benefit dollars. In 2013—the year nonprofit hospitals were first required to conduct and publish community health needs assessments (CHNAs)—he examined CHNAs and the resulting implementation plans for community health improvement developed by hospitals in 15 regions, looking at among other things how they defined their communities and engaged community stakeholders to identify problems and develop solutions.
Transforming Care: A first step in assessing community needs is identifying the community. Were you surprised by what you found about how hospitals went about this?
Barnett: In many ways yes. We selected a combination of large and small urban and rural areas that included census tracts where there was a high concentration of residents living in poverty and similarly high rates of high school non-completion. These metrics serve as effective proxies for higher concentrations of health disparities. We used a tool we developed in collaboration with the Community Commons to see to what extent hospitals included and described these areas in setting the geographic parameters for their CHNAs. We found less than a quarter of the hospitals identified these geographic areas in their CHNAs. In a number of cases, the definitions of their communities were driven by service areas identified by their marketing departments, based on zip codes and census tracts. When we mapped them, some looked like “gerrymandered” districts that steered around areas of poverty.
Transforming Care: Are IRS regulations part of the problem—don’t they suggest hospitals focus on their service areas rather than areas where there is unmet need or evidence of health disparities?
Barnett: That is part of the problem. On the one hand the IRS says hospitals should define their communities according to their service area but at the same time the agency indicates that hospitals should not define the geographic parameters of their CHNA in a way that would exclude communities where health disparities are concentrated. I think it’s a function of the parameters being drawn by people without population health expertise. Going forward, more clear and consistent guidance is needed from the IRS, given the market-based methods typically used by hospitals to define their service areas.
Transforming Care: Did you find they were engaging community members in the needs assessment process, as called for by the Affordable Care Act?
Barnett: About three-quarters of hospitals in the study had engaged local stakeholders in the assessment process, but less than a quarter of those gathered input directly from people who experienced health disparities, as they defined them. They relied primarily on community-based organizations as their proxies. The hospitals in the regions we looked at rarely engaged community members and organizations in planning and implementing community benefit activities—which are supposed to be shaped and prioritized based on the findings of the assessments. The IRS regulations released in December 2015 may change some of that because they signal an expectation that hospitals will involve community stakeholders in priority setting. It’s a shot across the bow to hospitals that they need to think of themselves as public trusts rather than proprietary organizations, and part of that involves collaborating with a broader group of stakeholders to determine how they allocate their charitable resources.
Transforming Care: What did the hospitals commonly identify as priorities?
Barnett: In the 2013 assessments, we found many were still very focused on clinical care, for example by increasing access to services including maternal and child health or improving the quality of care. Only 26 percent of the priorities they identified related to health behaviors such as diet and exercise and only 6 percent focused on social and economic factors that impede health such as education, employment, and community safety. At the time, none indicated a focus on improving the physical environment. This does not mean they were doing nothing in this arena, only that it was not addressed in their public reporting. What we have learned from a number of hospitals is that continued ambiguity about the degree to which the IRS will give hospitals credit for contributions in the community building category is an impediment to investment in this arena.
Transforming Care: Do you see this changing?
Barnett: Hospitals are now working on 2016 community health needs assessments and I expect to see more focus on community health and transformation. These efforts are likely to proceed at different paces, depending on whether hospitals are in states with Medicaid expansions or in markets where there is some level of shared risk emerging. To be economically viable, such hospitals eventually will have to go upstream. We are already seeing some hospitals and health systems moving a portion of their investment portfolios to supporting the development of housing, child care, and grocery stores as a way of improving health and quality of life. That said, I think it’s a hard shift for hospitals to go from focusing on what happens within their walls to looking at communities, especially those that may be outside of their primary service area. Hospital leaders have been consumed with implementing electronic medical record systems, addressing readmissions, and engaging in mergers and acquisitions. There’s a palpable sense of overload.
Transforming Care: I imagine that many hospital boards might say this isn’t an appropriate role for hospitals—that they should concentrate on improving clinical care and ensuring it’s cost-effective rather than solving entrenched social problems. How do you respond to those folks?
Barnett: The truth is that many boards are not engaged on these issues in any detail; the CHNA and implementation strategy are typically presented for board members’ review and approval, not as an opportunity to provide input. In my engagement of boards over the last decade plus, the most common response I get after sharing opportunities in the broader population health arena is “no one has ever shared this kind of information with me.” This is driven by a compliance mentality, and a failure by leadership to see the opportunity not to position the hospital to do everything, but to strategically engage other sector stakeholders as partners. As boards become increasingly informed about population health, I’ve found them to be ready to step up and support this important new direction. One of the things I am working on now is a partnership between Stakeholder Health (a coalition of health systems committed to addressing the social determinants of health) and the Governance Institute (an educational organization for hospital and health system boards), which brings board members and the senior leadership of hospitals together for a deep dive into content on population health and the intersection between community health and community development.
Transforming Care: Do you think hospitals have the skills and staff they need to do this work?
Barnett: The short answer is no. Frontline staff, clinical and administrative leadership, and boards need more grounding in population health principles and strategies, and these need to be embedded not just into community benefit programming, but also into care design, data systems, and management and governance. Another thing they need are metrics to evaluate the impact of a more integrated, strategic approach to community benefit. The metrics they are using now focus primarily on process—the number of people they’ve served for instance. We may not be able to measure aggregate impact at the population health level for several years but we should be measuring ways in which hospitals, public health agencies, and other key community stakeholders are changing the way they do business.
Transforming Care: What else might advance this work?
Barnett: I think we need to clarify expectations for defining communities to ensure hospitals are focusing on areas where health disparities are concentrated and we need to find ways of ensuring that opportunities for community input are meaningful. Right now hospitals are not required to post their implementation strategies on their sites, as is the case for their CHNAs. So it is difficult to build an environment of shared ownership where diverse stakeholders can participate in the design process. When implementation plans aren’t publicly disclosed, we encourage community stakeholders to ask hospitals these four questions: How are you defining your community? How are you engaging community stakeholders? How are you setting your priorities and with whom? And what is the geographic focus of your implementation strategies? Those four questions serve as an important starting point for improving practices in the field, not just by hospitals, but by all who share ownership for improving health and well-being in our communities.
Interviewed by Sarah Klein and Martha Hostetter.